


LIBRARY OF CONGRESS, 



Chap. . Copyright No... 

Shelf . J .C-B,.5»5i 



UNITED STATES OF AMERICA. 



UROPOIETIC DISEASES 



BY 



BUKK G. CARLETON, M. D., 

Author of Genito-Urinary and Venereal Diseases, Disorders of the 
Sexual Organs of Men, etc. 



SECOND EDITION, REVISED AND ENLARGED. 

Illustrated with 33 Photomicrographs and 6 Lucotype Figures. 



NEW YORK : 

BOERICKK & RUNYON CO. 

1900. 



IC^* 






72819 



COPYRIGHTED 



30654 



4 1900 j 

CoojngM entij 

PY, 

Delivered to 

ORDtf! DIVISION, 

AUG 7 1900 






BOERICKK & RUNYON CO. 

1900. 



PREFACE TO THE SECOND EDITION. 



Inasmuch as the disorders of the bladder have been 
included in this edition of the Medical and Surgical 
Diseases of the Kidney and Ureters, the title has been 
changed to Uropoietic Diseases. The size of the book 
has also been increased by the incorporation of many new 
sections and much new material has been added to the 
original articles, particularly those on the etiology of 
Bright's Disease and Uraemia. 

The success of the first edition has been greatly appre- 
ciated. If this volume refreshes the memory or in any 
way assists its readers, the author will be satisfied with the 
results of his efforts. 

Thanks are due Dr. Wm. F. Honan for the chapter on 
vesical calculi, to Dr. Geo. W. Roberts for the presentation 
of cystocopy, as applied to the diagnosis and treatment of 
urinary diseases of women, to Dr. Ephraim D. Klots for 
the chapters on urinary analysis and numerous photo- 
micrographs, and to Dr. Howard I,. Coles for valued 
assistance in proof reading. 

Bukk G. Carleton. 

75 West jotk St., N. Y. City, June, 1900. 



PREFACE TO THE FIRST EDITION. 



Many professional friends have requested me to prepare 
and publish a practical working companion volume to my 
Manual on Genito-Urinary and Venereal Diseases, so as to 
complete the subject of the Uropoietic diseases. In accord- 
ance with their request this monograph on the Medical 
and Surgical Diseases of the Kidneys and Ureters has been 
written and is now presented to the medical profession. 

It has been the aim of the author to incorporate all new 
facts from reliable sources, together with his personal ex- 
perience obtained at the Metropolitan Hospital and in 
private practice. Theories have been omitted and estab* 
lished facts only presented. 

The treatment of each disease, medical and surgical, is 
fully considered. 

As only brief drug indications have been given in the 
treatment of the different diseases described, the chapter 
on therapeutics must, therefore, be consulted when more 
complete symptomatic and clinical indications are required. 

The author is greatly indebted to Dr. E. D. Klots, 
Curator of the Metropolitan Hospital, for valuable assist- 
ance in the preparation of the sections on pathological 
anatomy and for the photomicrographic plates demonstrat- 
ing pathological changes, and to Dr. R. du Jardin for hi s 
assistance in seeing the manuscript through the press. 

November. 1808. 



TO THE 

COMMISSIONERS OF PUBLIC CHARITIES 

AND THE 

MEMBERS OF THE MEDICAL BOARD 

OF THE 

METROPOLITAN HOSPITAL, BLACKWELLS ISLAND, 

NEW YORK CITY, 

IN APPRECIATION OE THE CONSIDERATION AND MANY 

ADVANTAGES ENJOYED BY THE AUTHOR DURING 

HIS TWENTY-ONE YEARS' CONNECTION 

WITH THE HOSPITAL, 

THIS VOLUME IS 
RESPECTFULLY DEDICATED. 



CONTENTS. 



CHAPTER I, 
Anomalies of the Bladder. 

Non-development of the Bladder. Supernumerary Bladders. — 
Treatment. Cystocele. — Treatment. Exstrophy of the Blad- 
der. — Treatment. Patulous Urachus. — Treatment, 17 

CHAPTER II. 

Injuries of the Bladder. 

Wounds of the Bladder. — Clinical History. — Diagnosis. — Prog- 
nosis. — Treatment. Rupture of the Bladder. — Etiology. — Patho- 
logical Anatomy. — Clinical History. — Diagnosis. — Prognosis. — 
Treatment, 25 

CHAPTER III. 
Diseases of the Bladder. 

Acute Cystitis. — Etiology. — Pathological Anatomy. — Clinical His- 
tory. — Diagnosis. — Prognosis. — Treatment. Chronic Cystitis. — 
Etiology. — Pathological Anatomy. — Clinical History. — Treat- 
ment. Tubercular Cystitis. — Etiology. — Pathological Anatomy. 
— Clinical History. — Diagnosis. — Prognosis. — Treatment. Irri- 
tability of the Bladder. — Etiology. — Clinical History. — Treat- 
ment. Urinary Incontinence. — Clinical History. — Treatment. 
Strangury or Vesical Tenesmus. — Treatment, 31 

CHAPTER IV. 
Urinary Retention. 

Retention of Urine. — Pathology. — Clinical History. Retention 
from Congestion or Inflammation. — Treatment. Retention from 
Prostatic Enlargement. — Treatment. Retention from Sudden 
Obstruction of the Internal Opening of the Urethra. — Treatment. 
Retention from Paralysis or Incoordination of the Bladder 
Muscles. — Treatment. Retention from Urethral Stricture. — 
Treatment, 57 



10 CONTENTS. 

CHAPTER V. 
Vesicae Tumors. 

Papillomata. Adenomata. Mucous Polypi. Fibromata. Myo- 
mata. Angeomata. Serous and Dermoid Cysts. Carcinomata. 
Sarcomata. — Clinical History. — Diagnosis. — Prognosis. — Treat- 
ment, 69 

CHAPTER VI. 

Foreign Bodies in the Beadder. 

Etiology. — Clinical History. — Diagnosis. — Treatment, 77 

CHAPTER VII. 
Vesicae Caecueus. 
Etiology. — Clinical History. — Non-Operative Treatment. — Opera- 
tive Treatment. Stone in Female Bladder. — Treatment, .... 79 

CHAPTER VIII. 

Cystoscopy as Applied to the Diagnosis and Treatment of 
the Urinary Diseases of Women. 

Technique of Cystoscopy. — Preparation of the Patient. — Anaes- 
thesia. — Posture. — Asepsis. — Instruments. — Illuminations. 
Simple Cystoscopy. Ureteral Catheterization. Local Treat- 
ment Through the Endoscope. — Foreign Bodies. — Vesico- 
vaginal Fistulae. — Hyperemia of the Trigone. — Chronic 
Cystistis. — Tubercular Cystitis. — Tumors of the Bladder. — Treat- 
ment of Ureteral and Kidney Lesions, 96 

CHAPTER IX. 
Cystoscopy and Urinary Segregation 112 

CHAPTER X. 
Vesicae Therapeutics. 
Acidum benzoicum. — Acidum nitricum. — Acidum phosphoricum. — 
Aconitum napellus. — Aloe socotrina. — Alumina. — Apis mellifica. 
— Argentum nitricum. — Arnica montana. — Arsenicum album. — 
Aurum metallicum. — Belladonna. — Berberis vulgaris. — Calcarea 
carbonica. — Camphor. — Cannabis Indica. — Cantharis. — Carbo 
vegetabilis. — Causticum. — Chimaphila umbellata. — Chininum 
sulphuricum. — Coccus' cacti. — Colchicum autunmale. — Colocyn- 
this. — Conium maculatum. — Copaiba. — Cubeba. — Digitalis 
purpurea. — Dulcamara. — Equisetum hyemale. — Erigeron Cana- 
densis. — Eucalyptus. — Gelsemium sempervirens. — Graphites. — 
Hepar sulphuris calcarea. — Hydrastis canadensis. — Hyoscyamus 



CONTENTS. 11 

niger. — Ignatia amara. — Kreosotum. — L,achesis. — Lycopodium 
clavatum. — Murcurius. — Mullein oil. — Nux vomica. — Opium. — 
Pareira brava. — Petroleum. — Phosphorus. — Plumbum metalli- 
cum. — Pulsatilla nigricans. — Populus tremulus. — Prunus spinosa. 
Rhus aromatica. — Rhus toxicodendron. — Ruta graveoluns. — 
Sandal-wood. — Sabina. — Sabal serrulata. — Sarsaparilla. — Se- 
lenium. — Sepia. — Stigmata maidis. — Staphisagria. — Sulphur. — 
Terebinthina. — Thuja occidentalis. — Uva ursi. — Vesicaria com- 
munis , 1 20 

CHAPTER XI. 
Anomalies of the Kidneys and Ureters. 
Malformation of the Kidneys. — Nephroptosis. — Etiology. — Clin- 
ical History. — Diagnosis. — Treatment 134 

CHAPTER XII. 
Ureteral Injuries and Fistue^E. 
Rupture of the Ureter. — Etiology. — Clinical History. — Treatment. 
Ureteral Fistulae. — Clinical History. — Treatment 146 

CHAPTER XIII. 
Diseases of the Ureters. 
Ureteritis. — Etiology. — Clinical History. — Treatment. Ureteral 
Obstruction. — Treatment 149 

CHAPTER XIV. 
Diseases of the Peevis of the Kidney. 
Pyelitis. — Etiology. — Pathological Anatomy. — Clinical History. — 
Prognosis. — Treatment. Hydronephrosis. — Etiology. — Patho- 
logical Anatomy. — Clinical History. — Diagnosis. — Treatment. 
Pyonephrosis. — Etiology. — Pathological Anatomy. — Clinical 
History. — Treatment. Renal Colic. — Clinical History. — Prog- 
nosis. — Treatment ... 153 

CHAPTER XV. 
Renae Injuries and Fistue^E. 
Traumatism of the Kidney.— Etiology. — Clinical History.— Treat- 
ment. Renal Fistulae. — Etiology. — Clinical History. — Treat- 
ment 170 

CHAPTER XVI. 
Suppurative Nephritis. 
Etiology. — Pathological Anatomy. — Clinical History. — Treat- 
ment • - 175 



12 CONTENTS. 

CHAPTER XVII. 
Diseases of the Kidney. 
Acute Congestion of the Kidneys. — Etiology. — Pathological 
Anatomy. — Clinical History. — Prognosis. — Treatment. Chronic 
Congestion of the Kidneys. — Etiology. — Pathological Anatomy. 
— Clinical History. — Treatment. Acute Nephritis. — Etiology. — 
Clinical History. — Prognosis. — Treatment. Acute Degeneration 
of the Kidneys. — Etiology. — Pathological Anatomy. — Clinical 
History. — Treatment. Chronic Degeneration of the Kidneys. — 
Etiology. — Pathological Anatomy. — Clinical History. — Treat- 
ment. Bright's Disease. Acute Parenchymatous Nephritis. — 
Etiology. — Pathological Anatomy. — Clinical History. — Prog- 
nosis. — Treatment. Chronic Parenchymatous Nephritis. — 
Etiology. — Pathological Anatomy. — Clinical History. — Diag- 
nosis. — Prognosis. — Treatment. Interstitial Nephritis. — Etiol- 
ogy. — Pathological Anatomy. — Clinical History. — Diagnosis. — 
Prognosis. — Treatment. Amyloid Nephritis. — Etiology. — 
Pathological Anatomy. — Clinical History — Diagnosis. — Prog- 
nosis. — Treatment 178 

CHAPTER XVIII. 
Cystic Degeneration of the Kidney. 
Etiology. — Pathologicial Anatomy. — Clinical History. — Hydatids 
of the Kidney. — Etiology. — Pathological Anatomy. — Treatment, 233 

CHAPTER XIX. 

Renal Tuberculosis. 

Etiology. — Pathological Anatomy. — Clinical History. — Treatment, 236 

CHAPTER XX. 
Renal Syphilis. 
Acute Syphilitic Nephritis. — Etiology. — Pathological Anatomy. — 
Clinical History. — Prognosis. — Treatment. Chronic Syphilitic 
Nephritis. — Etiology. — Pathological Anatomy. — Clinical His- 
tory. — Treatment, 241 

CHAPTER XXI. 
Renae Tumors. 
Benign Growths of the Kidney. — Malignant Growths of the 
Kidney. — Etiology. — Clinical History. — Prognosis. — Treatment, 243 

CHAPTER XXII. 

Renal Calculi. 

Etiology. — Clinical History. — Treatment, 248 



CONTENTS. 13 

CHAPTER XXIII. 
Renal Surgery. 
General Consideration. — Nephrorrhapy. — Pyelolithotomy. — Ne- 
phrolithotomy. — Nephrotomy. — Nephrectomy, 254 

CHAPTER XXIV. 

ALBUMINURIA OF PREGNANCY. 

Etiology. — Pathological Anatomy. — Clinical History. — Treatment, 262 

CHAPTER XXV. 

Uremia. 
Etiology. — Clinical History. — Treatment 273 

CHAPTER XXVI. 
Abnormal States of the Urine Classed as Distinctive 
Conditions. 
Acetonuria. Albuminuria. — Treatment. Alkaptonuria. Bacteriuria. 
— Etiology. — Pathological Anatomy. — Clinical History. — Prog- 
nosis. — Treatment. Chyluria. — Etiology. — Clinical History. — 
Treatment. Cystinuria. — Etiology. — Clinical Histo^. Diace- 
turia. Globulinuria. Glycosuria. Haematuria. — Treatment. 
Hsemoglobinuria. — Etiology. — Clinical History. — Prognosis. — 
Treatment. Hydriothionuria. Indicanuria. Inosituria. Lac- 
tosuria. Larvulosuria. Lipuria. Melanuria. Oxaluria. — 
Etiology. — Clinical History. — Treatment. Phosphaturia. — 
True, functional, secondary. — Treatment. Pyuria. — Treatment. 
Polyuria. — Treatment. Uricaciduria. — Treatment, 293 

CHAPTER XXVII. 
Renal Therapeutics. 
Acidum aceticum. — Acidum benzoicum. — Acidum carbolicum. — 
Acidum gallicum. — Acidum nitricum. — Acidum phosphoricum. — 
Acidum picricum. — Aconitum napellus. — Adonis vernalis. — Am- 
monium carbonicum. — Ammonium picricum. — Apis mellifica. — 
Apocynum cannabinum. — Argentum nitricum. — Arnica mon- 
tana. — Arsenicum album. — Aurum muriaticum. — Belladonna. — 
Berberis vulgaris. — Caffeine. — Calcarea carbonica. — Camphor. — 
Cannabis Indica. — Cannabis sativa. — Cantharides. — Carbo vege- 
tabilis. — Causticum. — Cerefolius. — Chelidonium majus. — Chi- 
ninum sulphuricum. — Chloralum hydratum. — Cina. — Coccus 
cacti. — Colchicum. — Convallaria majalis. — Copavia. — Cuprum 
aceticum. — Digitalis purpurea. — Dulcamara. — Euonymin. — 
Eupatorium perfoliatum. — Equisetum hye"male. — Ferrum 
muriaticum. — Ferrum phosphoricum. — Formica rufa. — Graph- 



14 CONTENTS. 

ites. — Glonoinum. — Hamamelis Virginica. — Hedeomapulegioides. 
— Helleborus niger. — Helonias dioica. — Hepar sulphur cal- 
careum. — Hydrangea arborescens. — Ignatia amara. — Ipecacu- 
anha. — Kali bichromicum. — Kali carbonicum. — Kali chloricum. 
— Kali hydroiodicum. — Kalmia latifolia. — Lachesis. — Lithium 
carbonicum. — Lycopodium clavatum. — Mercurius corrosivus. — 
Mercurius dulcis. — Nux vomica. — Ocimum canum. — Opium. — 
Oxydendron arboreum. — Phosphorus. — Phytolacca decandra. — 
Pichi. — Pilocarpin muriaticum. — Plumbum metallicum. — Pul- 
satilla nigricans. — Rhus toxicodendron. — Sabina. — Sambucus. 
— Sandal-wood. — Sarsaparilla. — Secale cornutum. — Senecio 
aurens. — Senna. — Sepia. — Stigmata maidis. — Stramonium. — Sul- 
phur. — Terebinthina. — Thlaspi bursa pastoris. — Ulex diureticus. 
— Uranium nitricum. — Uva ursi. — Vesicaria communis. — Zingi- 
ber • • 313 

CHAPTER XXVIII. 

The Examination of Urine. 

Quantity. Color. Specific gravity. Reaction 339 

CHAPTER XXIX. 
Constituents of Normal Urine. 

Urea. Uric acid. Chlorides. Phosphates. Carbonates. Sul- 
phates. Oxalic acid 343 

CHAPTER XXX. 

Constituents of Abnormal Urine. 

Albumin. Globulin. Haemoglobin. Glucose. Mucin. Bile . . 351 

CHAPTER XXXI. 
The Clinical Significance of Urinary Deposits. 
Blood. Pus. Epithelioma. Tissue. Tube Casts. Bacteria. 
Parasites. Spermatozoa . 360 



Uropoietic Diseases. 



CHAPTER I. 

ANOMALIES OF THE BLADDER. 

NON-DEVELOPMENT OF THE BLADDER. 
Complete absence of the bladder is of rare occurrence. 
Only a few cases have been reported ; in these, the 
ureters either opened into the urethra, the rectum, the 
vagina, or upon the surface of the abdomen. It is usually 
associated with other anomalies which cause early death. 
If life is prolonged, a properly-fitting urinal or the im- 
plantation of the ureters into the rectum may be necessary. 

SUPERNUMERARY BLADDERS. 

These anomalies are infrequent. Mollinette reported a 
case of a woman with five distinct bladders, five kidneys and 
six ureters. Four of the uterers opened into individual 
and two into the largest vesicle. Multiple bladders are 
generally sacculated and communicate with each other. 
They may be simulated by dilatation of the lower ends of the 
ureters. 

Treatment. — If cystitis becomes troublesome and is not 
relieved by the usual medication, bladder drainage may be 
necessary. 

CYSTOCELE. 

When the linea alba is weak, deficient, or the aponeu- 
rosis of the external oblique is undeveloped, a congenital 



18 UROPOIETIC DISEASES. 

protrusion of the bladder may occur. Cystocele, however, 
is generally caused by some injury to, or disease of, the 
protecting walls of the bladder, its supporting parts, or 
both, as when the abdominal wall is weakened by a 
laparotomy or abscess, loss of adipose tissue, over-disten- 
sion, etc., or when the barrier at the inguinal, femoral, 
obturator or ischiatic foramen becomes deficient. In the 
female, cystoceles are common after child-birth. Defi- 
ciency in the support of the bladder is not in itself sufficient 
to cause a cystocele ; there must in addition be frequent 
over-distension of the viscus, straining during micturition, 
etc. When these conditions are present, and a portion of 
the bladder protrudes, a sacculation may form ; the portion 
of the wall involved loses its contractile power through 
frequent distension, and permits of a certain degree of 
retention, with possible decomposition of the retained 
urine and a resulting cystitis, which may terminate in 
ulceration, sloughing of the walls of the bladder or the 
formation of calculi. Cystoceles, unless of large size and 
preceded or accompanied by hernia, are, as a rule, not 
covered by peritoneum. 

Cystoceles may be mistaken for hernia, abscess of the 
groin, diseased conditions of the testes, etc. They increase 
in size with retention of urine, and decrease with urination 
or catheterization. They appear as soft, flaccid or tense 
tumors, giving dullness on percussion. If a cystocele 
becomes strangulated, the symptoms produced are similar 
to those of strangulated hernia, with the exception that 
the vomiting is always preceded by hiccough and there 
is, in addition, frequent and painful micturition. 

Treatment. — The bladder must be emptied at normal 
intervals and a properly-fitting truss worn at all times. 
If the cystocele is irreducible, the protruding parts should 
be returned to their normal positions and retained by 
proper repair of the deficent supports. 



EXSTROPHY OF THE BLADDER. 19 

EXSTROPHY OE THE BLADDER. 

This condition is due to failure of development of the 
anterior wall of the bladder and the corresponding por- 
tion of the abdominal parieties. The degree of non- 
development varies greatly, Hache describing nine varie- 
ties. When the bladder is intact but projects through 
an incomplete abdominal wall, the condition is known 
as ectopy vesicae uriuse. With this variety there may be 
lack of development of the pubic bones at the symphysis. 
True exstrophy always signifies a deficiency in the bladder 
wall. When situated high up and the symphysis pubis 
is not involved, it is termed a fissura vesicae superior; 
when in the lower portion and the symphysis is normal, 
it is a fissura vesicae inferior; when there is a deficiency 
in the anterior wall of the bladder and the pubic bones 
are separated at the symphysis it is an eversio vesicae. 

Exstrophy of the bladder is generally associated with 
malformations of neighboring parts, epispadias of the penis 
and clitoris being the most frequent. In some reported 
cases, the posterior wall was incomplete and communicated 
with and the intestines or rectum. Exstrophy occurs nine 
times more frequently in the male than in the female. 
Neudorfer says it happens once in every 100,000 births, and 
nine-tenths of the victims die within a few days. In this 
malformation the centre of the hypogastric region presents 
an irregular circular or oval bulging, rough, moist, bright 
red mucous surface, which bleeds easily, and varies in 
diameter from an inch in the infant to three inches in 
the adult. As a rule, there is no special cavity, though 
in the recumbent position there may be one oi consider- 
able size. The mucous surface ma}^ expand or bulge 
during inspiration or coughing, gurgling can at times 
be heard behind it ; it is sometimes reducible. Two 
small openings from which the urine trickles mark the 



20 UROPOIETIC DISEASES. 

orifices of the ureters. It is usually encircled by a zone 
of granulation tissue, and the surrounding skin is inflamed 
and excoriated. 

"Victims of exstrophy of the bladder as a rule become 
weak and debilitated, and die from some ascending inflam- 
mation of the urinary tract; the condition is, however, 
not incompatible with robust health. 

Treatment. — The patient can sometimes be made very 
comfortable with a properly-fitting urinal. If the ex- 
strophy is of any magnitude, surgical relief is not only 
indicated but will be demanded. As a rule, it should not 
be attempted until after the fourth year. The death rate 
in all surgical methods of cure is very high, and 
numerous successive operations are necessary to eradicate 
the defect or to even afford relief. 

When the fissure is small, the bladder cavity may be 
closed by denuding the edges of the cleft and uniting them 
with proper sutures, but if it is of any size it is advisable 
to first dissect off the requisite amount of mucous mem- 
brane, turn it into the bladder cavity and unite the de- 
nuded surfaces by proper sutures. If the exstrophy is of 
considerable magnitude, one of the following operations 
will be necessary, i. e., the implantation of the ureters 
into the rectum, the establishment of a fistula between 
the bladder and. the rectum, the dissection of the vesical 
mucous membrane, excepting that portion surrounding 
the openings of the ureters, and suturing it to the base 
of the accompanying epispadias, the uniting of the two 
margins by proper sutures and approximating the pubic 
bones at the symphysis, or by the cutaneous flap or auto- 
plastic method, which is the most frequently attempted. 
Numerous modifications of this operation have been sug- 
gested, but the two which have received the most favor are 
Wood's and Thiersch's. In some cases, these operations 
have been successful ; in others, while the bladder was 



EXSTROPHY OF THE BLADDER. 21 

not completely closed, the exposed surface was hidden and 
the point for discharge of the urine located where it ad- 
mitted of the successful application of a urinal. In many 
of the cases, however, the growth of the hair on the inverted 
skin forming the anterior wall of the bladder caused 
much annoyance and discomfort. Calculous formations 
have frequently occurred after this operation, sometimes 
requiring much technique in their removal. 

Wood's Operation. — All hair follicles in the area of the 
proposed skin flaps must be previously destroyed by elec- 
trolysis. In making and separating the flaps, care must be 
observed not to devitalize or injure them by rough manip- 
ulation or by making them too thin. The first flap is 
formed above the defective bladder, and must be of sufficient 
size when turned down to completely cover the exposed 
mucous surface, its length being equal to the distance 
from the root of the penis to the upper margin of the 
exposed bladder. It is outlined by an incision carried 
vertically upward the required distance from the side of 
the exposed viscus, thence convexly across the abdomen 
and down to a corresponding point on the opposite side of 
the mucous membrane. The lateral flaps, the raw sur- 
faces of which are turned inward and applied over the 
raw surface of the first, are rectangular in contour and 
attached by their pedicles to the base of the scrotum ; they 
are formed in the inguinal regions. The incision begins 
on the side of and is carried down one-half the length of 
the urethral groove. The flaps must be of sufficient size 
when dissected free to be approximated in the medium 
line without tension. The upper flap is secured with cat- 
gut sutures to the freshened skin border of the congeni- 
tal cleft and into the incision at the root of the penis. 
The inguinal flaps are sutured in the middle line and 
at the lower part, and brought closely together at the 
root of the penis. The raw surfaces from which the flaps 



22 UROPOIETIC DISEASES. 

are taken should be closed with plate sutures or hair-lip 
pins. 

Thiersch's Operation. — The flaps must be outlined 
much larger than is apparently necessary to allow of 
shrinkage. The first flap is made by an incision com- 
mencing at the upper border of the exposed mucous 
membrane, extending along its side to the root of the 
penis ; the second incision is made through the skin at 
the side of the cleft parallel to the first, and extends 
to Poupart's ligament. In width the flap should be two- 
thirds the vertical measurement of the exposed viscus. 
After the flap is dissected from the underlying tissues, it is 
separated from them for three weeks by a properly-shaped 
piece of tin-foil. At the end of three weeks the upper 
attachment is divided, and the divided end is carried across 
the lower part of the exposed bladder surface and secured 
by sutures to the freshened margins of that side. When 
this has united, a similar flap is cut on the opposite side, 
though the incisions are located higher, the lower point 
corresponding to the upper attachment of the lower 
flap. In three weeks this is separated and sutured to the 
freshened edges of the opposite side. When it is com- 
pletely united, the adjacent edges of the flaps are denuded 
and sutured ; the complete flap is then sutured to the upper 
border of the bladder, and finally, union of the lower 
border is attempted. This surgical procedure requires 
much time and patience. Incomplete union or failure 
is more frequent than union, and years may be necessary 
for its completion. 

Branth Operation. — The bladder is detached from its 
attachments above, the exposed mucous membrane, fresh- 
ened at the edge and united by L,ambert sutures. An in- 
cision is made just anterior to the scrotum and below the 
pubes, and the penis drawn out through it with a hook. 
In this manner the fundus and almost the whole bladder 



PATULOUS URACHUS. 23 

is brought down into the pelvis, behind the pubes, where 
it is fastened by catgut sutures to retain it in its normal 
position. The root of the penis is made raw and united 
to the wound, through which it now protrudes. The 
tendinous portions of the transversalis and oblique muscles 
ensheathing the rectus muscles are easily sutured by a 
continuous or recurrent suture, similar to that employed in 
modern perineorrhaphy which secures firm union. The 
urine being discharged through the groove in the epispadic 
penis of the defective urethra. L/ater, efforts will be neces- 
sary to form a roof to the urethra, a problem, which seems 
possible of solution. 

MaydPs operation for implantation of the ureters into 
the intestine is sometimes successful. The peritoneal cav- 
ity is opened along the borders of the defect, ureteral 
catheters introduced, and the entire mucous membrane, with 
the exception of a small oval portion surrounding the ori- 
fice of each ureter, is resected. This section is made freely 
movable by dissection, and sutured into a longitudinal 
opening of sufficient size in the colon. The first line of 
sutures unites the mucous membranes, the second the 
serous and muscular coats of the gut, and the operation 
is completed by closing the abdominal cavity as in a 
laparotomy. 

PATULOUS URACHUS. 

This congenital defect is infrequent ; it may be complete 
or incomplete. When complete the urine escapes at the 
umbilicus ; when incomplete, it may be one of three 
varieties, i. <?., the urachus open at the vesical end and 
closed at the umbilicus, open at the umbilicus and closed 
at the vesical end, or closed at both ends but patent 
throughout the remainder of its length. The latter variety 
presents an elongated cystic tumor which occupies the 
position of the urachus. 



24 UROPOIETIC DISEASES. 

Treatment. — If the urinary leakage is due to some occlu- 
sion of the natural outlet, the obstruction must be removed 
by a proper urethrotomy or meatotomy. The patulous 
urachus may be cauterized, its surfaces denuded and 
approximated by proper sutures, or after an incision 
made through the linea alba, the urachus found and 
divided, the lower end may be invaginated into the bladder 
and properly sutured. The last operation is especially 
indicated when the urachus contains a calculus or is patent 
only in its central portion. 



CHAPTER II. 
INJURIES OF THE BLADDER. 

WOUNDS OF THE BLADDER. 

Wounds of the bladder, unless due to direct puncture by 
bullets, horns, or pointed stakes, are uncommon. There 
are four routes by which the bladder can be accidentally 
wounded without injury to its bony protecting walls, i. e. y 
through the abdominal parieties, the perineum, the rectum, 
or the obturator foramina. The greater the degree of dis- 
tension of the bladder at the time of the accident, the 
more readily can it be penetrated. 

Wounds of the bladder may be punctured, incised or 
contused. Punctured wounds vary in importance accord- 
ing to their size, the condition of the urine and the facility 
for immediate surgical repair. Puncture by the aspirator 
needle, etc., unless a vessel is wounded or ulceration fol- 
lows about the minute opening, is generally unimportant ; 
if the urine is septic or the needle unclean many 
unpleasant conditions may result. Incised wounds are 
generally made accidentally or designedly by the surgeon. 
If properly closed they do well ; if overlooked, most serious 
consequences may follow. During an operation, they may 
be avoided by introducing a sound in the bladder and 
moving its point from time to time. Contused wounds 
are frequent, and may be caused by falling astride a picket 
fence, being gored by the horn of an animal, penetrated by 
a bullet, etc. If the pelvic bones are shattered by a bullet, 
spiculae of bone may be thrust through the bladder walls 
and cause a bad laceration. 

Wounds of the bladder may also be classified as non- 



26 UROPOIETIC DISEASES. 

penetrating and penetrating. The non-penetrating or 
simple traumatism of the external or internal wall of the 
bladder may accidentally happen, as during the removal of 
a peri-cystic growth with adhesions, or wounded by the 
lithocrite in the removal of a stone, etc. Penetrating 
wounds may be intra- or extra-peritoneal, or both. 

Clinical History. — Immediately after the bladder is 
wounded, many of the symptoms, in addition to those of 
shock, will depend upon the associated injuries of adjacent 
organs. Urine may escape from the wound continuously, 
intermittently, or only when there is a desire to urinate, 
the rent in the interval being closed by a flap of tissue or 
a valve-like plug of the loose mucous membrane. The 
fluid discharged from the wound may be clear, bloody, or 
consist of blood and clots. It may escape into the peri- 
toneal cavity. The calls to urinate are often frequent and 
painful, though little or no urine is voided. The second- 
ary symptoms vary with the condition of the urine, 
whether the penetrating instrument was septic or aseptic, 
and whether the wound was intra- or extra-peritoneal. 
Extra-peritoneal wounds of the bladder are the least serious, 
though urinary infiltration and decomposition in the 
tissues are common complications. When the wound is 
intra-peritoneal, the blood and clots with septic urine, or 
urine ready to undergo decomposition, etc., escaping into 
the peritoneal cavity, will produce chills, fever, septic 
infection, acute infective peritonitis, etc., with often fatal 
results. 

Diagnosis. — This can generally be made by a study of 
the direction of the penetrating object and the course 
pursued by the urine after it escapes from the bladder. 
If the wound is intra-peritoneal, the urine may pass into 
the peritoneal cavity. By introducing a sound or similar 
instrument into the bladder and passing a long silver probe 
through the wound, it may be possible to demonstrate the 



RUPTURE OF THE BLADDER. 27 

connection of the external opening with the one in the 
bladder. When there is a question of doubt, immediate 
laparotomy and closure of the wound, if discovered, is 
indicated. 

Prognosis. — Surgical wounds, if recognized and properly 
repaired, do well. Those produced by instruments intro- 
duced through the rectum and vagina are more serious than 
when they are introduced through the perineum or hypo- 
gastrium. All contused wounds are dangerous. 

Treatment. — If intra-peritoneal, laparotomy and repair 
of the bladder wound, with proper vesical drainage for at 
least three days. If extra-peritoneal, closure of the wound 
with the L/ambert suture without including the mucous 
membrane and the institution of proper bladder drainage. 

RUPTURE OF THE BLADDER. 

Etiology. — This accident occurs eight times in ore fre- 
quently in men than in women, owing to their more 
active out-door and exposed life, generally happening be- 
tween the twelfth and fiftieth years, although cases in 
children under two years of age have been reported. The 
causes of rupture are predisposing and exciting or direct. 
Over-distension of the bladder is an exceedingly important 
predisposing factor in intra-peritoneal and to a less degree in 
extra-peritoneal rupture, as distension not only diminishes 
the thickness of the bladder wall, but brings it into closer 
proximity with the abdominal parietes and above the 
protection of the bones of the pelvis. Insensibility also 
predisposes to rupture, the abdominal wall ordinarily 
acting as a flexible resistant barrier to external violence. 
The direct causes of rupture may be traumatic or patho- 
logical ; it may occur idiopathically. Rupture may be 
caused by over-muscular exertion or violence from within 
or by falls or blows upon the abdomen, from crushing 
of the pelvis and perforation of the viscus by pieces of 



28 UROPOIETIC DISEASES. 

broken bone, or from indirect force, as falls upon the feet, 
the back, or the tuberosities of the ischia, and the usual 
forms of violence from without. Violent muscular action 
may produce rupture, as when pushing or lifting, strug- 
gling under an anaesthetic, or straining to urinate when 
the bladder is full from retention due to stricture, enlarged 
prostate, or other obstruction. Pathological lesions, ulcer- 
ating and gangrenous inflammations of the bladder walls 
may so thin and weaken them as to allow rupture to take 
place. Constant pressure from a retroverted uterus has 
caused it. Idiopathic or spontaneous rupture, when the 
bladder walls are healthy, is very infrequent. It has oc- 
curred from simple overdistension in cases where it was 
impossible to obtain surgical relief. The over-distension 
may be due to urinary retention from stricture of the 
urethra, tumors, enlarged prostate, retroversion of a gravid 
uterus, or insensibility from alcoholism, fevers, hysteria, 
etc. 

Pathological Anatomy. — Traumatic rupture generally 
presents a rent of from one to two inches in length in the 
wall of the bladder; the idiopathic, a small circular or 
trigonous opening; the pathological, varies in contour 
with the lesion producing it. Rupture generally takes 
place in the posterior wall and, when intra-peritoneal, the 
laceration is usually vertical, though it may be oblique or 
transverse. Rents produced by traumatism are, as a rule, 
located in the upper portion of the posterior wall. Spon- 
taneous rupture also takes place in this location. One 
or all the coats of the bladder wall may be involved. The 
mucous and muscular may alone give way and allow the 
urine to dissect up into the peritoneum and infiltrate the 
areola tissue. The bladder often continues to functionate 
in a varying degree, or it may be found contracted like a 
hard ball. When the rupture is intra-peritoneal, a large 
amount of blood often escapes with the urine into the 



RUPTURE OF THE BLADDER. 29 

abdominal cavity, and if death occurs within three days a 
large amount may be present without evidence of peri- 
tonitis; in fact, the peritoneum absorbs normal urine 
rapidly. If death occurs after three days, and the urine 
was septic or unclean instruments were used, evidences of 
peritonitis will usually be found. In extra-peritoneal 
rupture, urinary infiltration, etc., develops rapidly, depend- 
ing upon the location and degree of the tear. 

Clinical History. — Rupture of the bladder is attended 
with intense pain in the region of the organ and a feeling 
as if something had given away. It is followed by vomit- 
ing, and often by faintness, or even collapse, with all the 
symptoms of shock. Standing or walking is generally 
impossible. If retention preceded the rupture, the initial 
pain is followed by a sense of relief, which is, however, 
soon succeeded by excruciating pain radiating over the 
abdomen. The desire to urinate becomes urgent and 
troublesome, though only a few drops of blood and urine 
are discharged per urethra. Generally, but little urine is 
voided voluntarily, though there are numerous exceptions. 
On catheterization only a little bloody urine will be 
obtained. If the rupture is intra-peritoneal, the end of 
the catheter may be outlined at a point in the abdominal 
cavity external to the bladder region. The passage of 
fluid through the catheter is often quickened by the respira- 
tory acts. The quantity discharged may vary from a few 
to many ounces, and contain a varying number of blood 
clots which may obstruct the catheter. When the rup- 
ture is intra-peritoneal, a moderately well-defined fluctuat- 
ing tumor is often formed between the umbilicus and the 
pubes, or in the recto-vesical space. In extra- peritoneal 
rupture, the exuded urine produces a doughy, asymmetri- 
cal swelling ; if the rent is in the anterior wall, this swell- 
ing may extend above the symphysis pubes and over the 
abdomen ; if in the posterior wall, the swelling will form 



30 UROPOIETIC DISEASES. 

between the bladder and the rectum and extend out from 
the side on which the tear is most prominent. The urine 
may by dissection diffuse and spread upward in front of 
the peritoneum over the abdomen, downward through the 
obturator foramina or the inguinal rings into the scrotum, 
and through the femoral rings to the thighs, etc. Abscess 
and sloughing generally follow, with pain, chills, fever, 
vomiting, general depression, and all the symptoms of 
general septic infection. 

Diagnosis. — In extra-peritoneal rupture, urinary extra- 
vasation usually appears within a few hours. When intra- 
peritoneal, the ability to pass a catheter into the peritoneal 
cavity through the rent in the bladder wall and the empty 
viscus will be diagnostic. The injection of a large 
amount of warm antiseptic solution through the catheter 
may be of great diagnostic value. In cases of doubt, 
immediate laparatomy for diagnosis and repair of the 
laceration is justified. When accompanied by fracture of 
the pelvic bones the rupture is generally extra-peritoneal. 

Prognosis. — Rupture of the bladder usually terminates 
fatally, though, if immediately repaired, recovery may 
ensue. 

Treatment. — If the rupture is extra-peritoneal, con- 
tinuous urethral drainage by a large catheter, with care 
that it does not become obstructed, and incision of the 
infiltrated cellular tissue with its proper drainage, pos- 
sibly, a median, or a lateral perineal cystotomy, will be 
more desirable. If intra-peritoneal, laparotomy, removal 
of the clots and urine, and proper closure of the wound by 
two rows of sutures, the first including the mucous and 
muscular coats and the second the serous, together with 
the institution of continuous drainage per urethra, or an 
external urethrotomy and perineal drainage may be ad- 
visable. 



CHAPTER III. 

DISEASES OF THE BLADDER. 

The clinical manifestations which indicate inflammation 
of the bladder may depend primarily upon the presence in 
that viscus of certain ptomaines, chemical or toxic mate- 
rials, upon a necrobosis from nerve lesions, traumatism, 
etc., as well as upon the various forms of pyogenic and 
other micro-organisms. Cystitis is never idiopathic but 
always secondary to some associated abnormal condition. 
It may be acute or chronic. 

ACUTE CYSTITIS. 

Etiology. — The causes of acute cystitis may be classi- 
fied as predisposing and determining. The predisposing 
include tuberculosis, gout, rheumatism and continued 
fevers with their toxic urines ; chilling of the body surface, 
improper and highly seasoned foods, particularly alco- 
holics ; anything which increases the acidity of the urine, 
conditions producing congestion of the bladder, as stone 
or new growths, over-distension from prostatic enlarge- 
ment, urethral stricture, or mental stupidity from disease, 
as well as the too-rapid evacuation of an over-distended 
bladder. Disease and injury to the spine may cause con- 
gestion of the bladder as well as traumatism, masturbation, 
excessive coitus, haemorrhoids, etc., or the ingestion of 
Cantharides, Turpentine, Bichloride of mercury, some of 
the balsams, etc. 

The determining causes include not only gonorrhceal 
and all other pyogenic urethral germs, which by con- 



32 UROPOIETIC DISEASES. 

tiguity of surface may travel or be forced into the bladder 
by instrumentation, but when predisposing conditions are 
present, fatigue, sexual excesses, horseback or bicycle 
riding, traumatism, as after child-birth, etc., may favor 
the backward movement of any inhibited urethral micro- 
organisms and the production of an attack of acute 
cystitis. The most common determining germ, however, 
is the bacillum coli commune, which may enter the 
bladder by the way of the kidneys or directly through the 
lymphatics. The urobacillus liquefacieus, the bacillus 
griseus, the diplococcus favus, and the staphlococcus are 
also often the determining factors ; they may enter the 
bladder in various ways. Acute cystitis may originate 
from the presence of irritants in the urine, either derived 
indirectly from indigestion or directly from improper or 
excessive bladder douches, or from the presence of dead 
tissue caused by imperfect innervatioa. 

Pathological Anatomy. — The trigone is chiefly in- 
volved, the mucous membrane appearing red, swollen and 
inflamed, covered with a mucous exudate, with here and 
there erosions of the epithelium. The blood vessels are 
prominent. In severe cases, the whole mucous membrane 
may be exfoliated as the result of over-distension or diph- 
theritic exudation. The muscular and serous coats also 
show evidence of inflammatory changes. Small abscesses 
may develop and open into the bladder and leave ulcers. 
Gangrene has sometimes resulted. If the cellular tissue 
between the muscular and peritoneal coats is involved, it 
constitutes a peri-cystitis. 

Clinical History. — The symptoms vary greatly in in- 
tensity. Sometimes there is only a slight increased 
desire to urinate, followed by an unsatisfied feeling which 
passes off in a few hours or days. In the graver cases 
there is a constant, irresistible desire to urinate and often 
inability to retain the urine, accompanied with tenesmus,. 



ACUTE CYSTITIS. 33 

burning, smarting and stinging pains during the act, 
which disappear shortly after its completion. The pain 
is referred to the neck of the bladder, the end of the penis, 
or the perineum, and extends down the thighs, and varies 
in degree with the frequency of the calls to micturate. 
Soreness and uneasiness in the region of the bladder 
is generally present, and is greatly increased by palpation 
over the hypogastric region, or by examination per rectum, 
or vagina. Intra-vesical tenderness is particularly notice- 
able, and the presence of an associated calculus in the 
bladder produces much pain. Attempts to distend or to 
wash the bladder with antiseptic solution excites great 
pain and tenesmus. Pus may not at first be present in 
the urine. When present it is diffused throughout the 
urine, giving it a milky appearance. The cloudiness is 
most marked at the beginning and the end of urination. 
Fever is absent in acute cystitis unless there is an accom- 
panying prostatic, peri-vesical or uretero-renal inflammation. 

The gonorrhoea! variety may appear during the second, 
though rarely before the third week of a specific urethritis. 
It varies greatly in duration and intensity. The gonor- 
rhoea! discharge lessens or ceases on the appearance of the 
cystitis to return on its cure. Fever is absent. Tenesmus 
and frequent desire to urinate are especially noticeable. 
The urine has a milky or bloody prune-juice appearance, 
and contains a tenacious, stringy matter resembling thin 
glue. When allowed to stand, it separates into an upper 
or clear layer and a lower greenish, thick sediment com- 
posed of pus and blood, some blood clots, and numerous 
micro-organisms, as above mentioned. The microscope 
reveals pus and blood corpuscles, crystals of triple phos- 
phates and other products of inflammation. 

The severe types of acute cystitis arise from the intro- 
duction of micro-organisms by means of unclean instru- 
ments, traumatism or diphtheria. 



34 UROPOIETIC DISEASES. 

Diagnosis. — There are three cardinal symptoms which 
are always present in acute cystitis — frequent micturition, 
painful micturition and purulent urine. When the entire 
interior of the mucous membrane of the bladder is 
involved, the pus will be equally diffused through the 
urine voided ; when the first and last portions of the urine 
voided show an excess of pus, and there is excessive 
pain when the parts are examined per rectum or vagina, 
the disease is probably confined to the region of the tri- 
gone. Peri-cystitis is always accompanied with fever and 
generally tumefaction, which can be distinguished by 
rectal or vaginal examination; signs of deep-seated sup- 
puration are usually present. 

Prognosis. — Acute cystitis generally responds quickly 
to treatment, though recovery depends greatly upon the 
cause and the ease with which it can be removed. 

Treatment. — If caused by stricture, stone, etc., surgical 
relief is indicated. When there is evidence of retention, 
and percussion and palpation show an enlarged, distended 
bladder, catheterization under strict antiseptic methods is 
often necessary. Rest in bed is essential in all severe 
cases, with hot fomentations and poultices to the 
hypogastric region and perineum. The diet must be 
light, farinaceous, easy of digestion and non-irritating; 
milk is the classical food. Bladder douches are to be 
avoided, though the instillation of a few drops of a solu- 
tion of Nitrate of silver, i to 2000, to 1 to 500, often 
greatly mitigates the pain, etc. When the tenesmus 
does not yield to treatment, a perineal or supra-pubic cys- 
totomy followed by continuous drainage may be required 
to give immediate relief and rest to the bladder. When 
the result of cold, Dulcamara will be of great benefit. 
If accompanied by fever and stranguary, Aconite, Gel- 
semium, Cantharis, Capsicum, Belladonna, Tarantula, Pul- 
satilla, Nux vomica, Uva ursi, Terebinth, Prunus spinosa, 



CHRONIC CYSTITIS. 35 

Copaiva and Oil of Sandalwood are frequently indicated. 
Triticum repens or Flaxseed tea will often be beneficial. 

The strangury may require Hydrangea or Stigmata 
maidis in twenty-drop doses of the tincture frequently 
repeated, or rectal suppositories containing one grain of 
Opium and one-fourth grain of extract of Belladonna. 

CHRONIC CYSTITIS. 

Etiology. — Chronic cystitis is always secondary to some 
other diseased condition. It may be the sequel of an 
acute cystitis. All of the etiological factors mentioned 
under acute cystitis are also in evidence in the chronic 
form, particularly stricture of the urethra, diseases of the 
prostate, growths of various kinds which by contiguity 
of tissue interfere with the normal exit of the urine. 
It may be produced by reflexes from spinal injury or arise 
from sexual excesses, stone in the bladder, retention of 
urine, or follow pyelitis, nephritis, pyelo-nephritis, etc. 
The most frequent cause, however, is the introduction of 
bacteria into the bladder by unclean instruments. The 
bacilli coli communi, which are more common in cys- 
titis than all the other germs, may enter the bladder 
through some undiscovered channel, through the lym- 
phatics, or escape into the urinary stream through the 
kidneys. Intemperance and individual idiosyncrasy often 
modify the disease. Acute or sub-acute attacks may at 
any time be engrafted on a chronic condition from cold, 
exposure, instrumentation, etc. 

Pathological Anatomy. — The disease usually com- 
mences at the neck and fundus of the bladder, involving 
first the mucous coat ; in the severe varieties it soon ex- 
tends to the muscular and serous coats. In some of the 
older cases the membrane is pale, and may present no 
marked pathological changes to the eye when examined, 
either at the autopsy or during life. The Fennick-Leiter 



36 UROPOIETIC DISEASES. 

cystoscope, an instrument shaped like an ordinary sound > 
with a small Swan lamp fixed in the beak, greatly facili- 
tates examination of the bladder cavity. It may be neces- 
sary to use local or general anaesthesia to introduce the 
instrument, but as a rule the parts are not over-sensitive, 
and it is easily passed into the bladder in the absence of 
stricture or other obstructions of the urethra. The bladder 
must be washed with a Boric acid solution ; after the fluid 
returns clear at least four ounces must be injected for 
successful cystoscopic examination. It requires much 
practice and persistence to appreciate the normal and 
abnormal conditions revealed by the cystoscope. 

The membrane, however, is generally swollen, congested 
and less firm than normal, with extravasated blood in 
spots. The vessels are enlarged and varicosed, filled with 
dark blood, with here and there erosions and ulcerations 
of the mucous coat. The latter is covered with glairy 
mucus or a chocolate-colored fluid, composed of broken- 
down cells, ammoniaco-magnesian phosphates, etc. 

The ureters may be inflamed, dilated, and contain much 
pus, which may even completely occlude them. The pelvis 
of the kidney and even the kidney tissue may present 
evidences of inflammation and of compression from retained 
urine. Such pathological changes account for the poly- 
uria sometimes present. 

The cellular tissue of the vesical wail may be infiltrated 
with inflammatory products that undergo retrograde meta- 
morphosis and finally breaks down, or the mucous mem- 
brane may be ulcerated and expose the muscular coat. 
The muscular coat may be hypertrophied, with or without 
accompanying bladder dilatation. Sometimes contraction 
of the viscus occurs, due especially to the irritation of an 
acid urine, but usually it is dilated from atonicity. The 
muscular coat may be atrophied here and there, allowing 
the development of pouches, whose walls are composed of 



CHRONIC CYSTITIS. 37 

the mucous aud serous coats only ; the muscles may, on 
the other hand, stand out like large bands or cords, which 
are of a deep bluish-red or purple color. They are some- 
times eaten through and project as stumpy, ulcerated 
masses into the cavity of the bladder. Sometimes ulcera- 
tion between the muscular bands occurs and perforation 
into the peritoneum and adjacent parts results. 

When the disease is of long standing the walls of the 
bladder may become dilated and thinned, the cavity saccu- 
lated, and sometimes contain from two to eight pints of 
alkaline, foetid, chocolate-colored urine. 

Clinical History. — This varies greatly with the source 
and duration of the disease. The exciting cause will 
govern not only the severity of the disease but also 
the persistence of this or that symptom or set of symptoms, 
and will vary from a moderate case presenting increased 
frequency of micturition, slight uneasiness and burning 
during the act with an uncomfortable feeling referred to the 
sub-pubic region, to one in which the desire to urinate is 
constant and attended with the most agonizing burning 
pains and tenesmus. 

The general health is impaired by the retention in the 
circulation of urea, an associated diseased condition of the 
kidney often preventing its proper elimination, as well 
as the introduction into the system through the diseased 
bladder of bacteria and their ptomaines. 

This systemic toxaemia is recognized by the great 
prostration, emaciation, weakness, thirst, hectic fever, rest- 
lessness, constipation, sometimes diarrhoea, and, if the case 
is to terminate fatally, by a low or typhoid state, with dry 
tongue, irritable stomach, uriniferous breath, delirium and 
coma. 

The condition of the urine varies with the duration of 
the disease, the pathological conditions and the character 
of the micro-organisms present, the bacilli coli com muni 



38 UROPOIETIC DISEASES. 

being the most frequent, and the staphylococci next; 
the micrococcus urea is less common. Some or all are 
always present in a varying degree. The urine may 
be mildly acid, turbid or milky, containing pus, albumen 
and epithelium. As retention becomes persistent the 
urea gradually decomposes into carbonate of ammonia 
which attacks the mucous membrane and add still further 
to the existing pathological changes. The retained urine 
is alkaline from ammoniacal decomposition and neutralizes 
the acid urine as it flows from the ureters. The pus and 
mucus are converted into a yellow, stringy tenacious, 
mass, which may be drawn out into long strings without 
parting, and contains in its meshes ammoniaco-magnesian 
and amorphous phosphates, blood corpuscles, etc. In the 
advanced state of the disease the urine becomes chocolate- 
colored, of pungent and ammoniacal odor, micturition 
frequent and agonizing, especially towards the end of 
the act, with pain referred to the sacrum, lower part of 
the abdomen, penis, back and thighs. If atony and dila- 
tation are present to any extent the tenesmus will increase 
in violence and dribbling of the urine from overflow 
occurs, the quantity passed at each urination being only 
the excess accumulated between the acts. The overdis- 
tended bladder may sometimes extend as high up as the 
umbilicus. 

Treatment. — If rapid and permanent results are desired 
in the treatment of chronic cystitis, the removal of the 
cause and the local treatment must be associated with the 
administration of the indicated remedy, which must always 
be given in accordance with its special symptomatic indi- 
cations. 

Benzoic acid : Urine high-colored, strong smelling,, 
cadavorous ; specific gravity increased from increase in 
volume of uric acid. It often contains mucus and pus. 
this drug acts especially well with gouty subjects who are 



CHRONIC CYSTITIS. 39 

annoyed by incontinence of retention, as well as those suf- 
fering from loss of power of the bladder walls, or irritation 
of the bladder walls by the highly concentrated urine. 
Dribbling is continuous, often accompanied with frequent 
calls to urinate with much tenesmus. 

Chimaphila umbellata : Urine high-colored, bloody, with 
a greenish sediment, or large quantities of ropy, slimy, 
fetid mucus. No other remedy is so frequently indicated 
for chronic cystitis. The calls to urinate are frequent and 
may or may not be accompanied with vesical tenesmus ; 
often there is inability to urinate except when standing 
with the feet well separated. Another symptom which is 
characteristic is a sensation of swelling in the perineum, or 
as though a ball had been forced into the anus. 

Copaiva : Urine greenish, turbid, bloody, smells like 
violets, containing yellow mucus. This remedy is often 
useful in the cystitis of gonorrhceal origin where the mic- 
turition is accompanied with much vesical tenesmus. 

Dulcamara: Urine viscid, turbid, whitish, sediment 
thick, stringy, composed of mucus of offensive odor. 

Eucalyptus : Urine scanty, foul-smelling, and contains a 
large amount of muco-purulent sediment ; micturition is 
accompanied with much burning and smarting, together 
with general malaise and fever. Its sphere of usefulness 
is especially found in the urinary fever accompanying 
chronic cystitis, with afternoon chill, hectic fever and night 
sweats. 

Nitric acid : Urine ammoniacal with white sediment. 
Urine cold when voided. This remedy is especially useful 
in the cystitis and incontinence of old men having the 
peculiar symptoms of intense urging to micturate immedi- 
ately after the act, with shuddering along the spine. 

Berberis vulgaris : Urine yellow or red with a bran-like 
sediment, often of a greenish cast, containing a transparent 
gelatinous sediment, or a copious clay-colored flocculent 



40 UROPOIETIC DISEASES. 

mucus deposit. Micturition is increased in frequency, 
with burning before and during the act. Violent con- 
strictive pains in the bladder whether full or empty. Vio- 
lent stitching, tearing, burning pain in the region of the 
kidney, extending forward along the course of the ureters 
into the bladder, and down the posterior part of the pelvis, 
aggravated when stooping, lying or sitting ; relieved by 
standing. 

Pareira brava: Urine ammoniacal, containing thick viscid 
mucus ; micturition accompanied with great burning and 
violent straining, associated with pain extending into the 
glans penis down the thighs and even into the feet. This 
pain is often so agonizing that urination is only possible 
when on the knees and the head pressed against the floor. 

Pulsatilla : Urine red in color, sediment jelly-like and 
slimy, often adhering to the vessel. Frequent almost 
ineffectual urging to micturate ; constant pressure and de- 
sire to urinate. Pain in the bladder extending to the pel- 
vis and thighs. Urinary retention with heat and soreness 
in the vesical region. Involuntary discharge of urine 
drop by drop at night on walking or coughing. Urinary 
stream intermittent. Constricted pains in the bladder at 
the end of micturition. 

Sabal serrulata : Frequent calls to urinate ; micturition 
unsatisfactory ; urine voided in drops accompanied with 
intense tenesmus. Incontinence of retention. The cystitis, 
which is relieved by Sabal, has an accompanying symp- 
tom, muscular jumping of the body on lying down to sleep, 
which often awakens the patient. The cystitis, which is 
relieved by Sandal wood, has an accompanying dull heavy 
pain across the lower part of the lumbar region. 

Sulphur : Urine high-colored, turbid, excoriating, often 
having a penetrating odor, with a thick deposit that ad- 
heres to the chamber. Urine is often increased in quantity. 
The desire to micturate comes suddenly and imperatively ; 



CHRONIC CYSTITIS. 41 

if not gratified at once, the urine will be voided involun- 
tarily. Frequent calls to micturate, especially at night, 
with a sense of obstruction at the neck of the bladder and 
a sensation of pressure and distension. Bruised sensation 
in the small of the back after urination. 

Thuja occidentalis : Urine clear when voided, but becomes 
cloudy on standing ; frequent calls to micturate during the 
night ; urging to urinate ; the stream is often interrupted. 
Stitch-like pain from the rectum to the bladder and from 
the bladder to the urethra. Incontinence from paralysis of 
the internal sphincter as well as the incontinence of 
retention. 

Chronic cystitis often responds unsatisfactorily to 
treatment owing to inability to remove the cause. As 
the condition is always secondary to some previous 
physical deficit, in the degree in which the predispos- 
ing cause can be eradicated can the practitioner reason- 
ably expect to benefit the patient. Therefore, all urethral 
obstructions, strictures, new growths, calculi, prostatic 
overgrowths, etc., must be removed. If a balano-post- 
hitis exists, it must have appropriate treatment; cir- 
cumcision may be required. The bladder must be inter- 
rogated with the stone searcher and the cystoscope ; if 
overgrowths or calculi are present, they must receive 
appropriate treatment. Out-of-door employment, as con- 
sistent with the strength of the patient, must be com- 
mended; the hours of sleep must be carefully regulated and 
observed. Carriage-riding and wheeling are usually bene- 
ficial, but must never be carried to the point of producing 
fatigue. Recumbent and sitting postures are often harm- 
ful. A hot or cold sponge bath should be taken every 
morning, followed by vigorous rubbing of the surface of 
the body with a coarse bath towel, and a Turkish bath 
once a week. The diet must be non-irritating and easy 
of digestion. Heavy meals and unseasonable foods, espe- 



42 UROPOIETIC DISEASES. 

cially alcoholics and deserts, must be avoided. The bowels 
must be carefully regulated ; constipated conditions, by in- 
terfering with the exit of the bacilli coli communi, 
increase the number in the intestinal canal and the con- 
sequent liability of their passing through various chan- 
nels into the bladder. Charcoal, ten grains, or Naphthalin, 
three grains, in a gelatine capsule, administered three 
times daily, not only controls the intestinal condition but 
prevents increased bladder infection. If exercise and diet 
do not regulate the daily evacuation of the bowels, saline 
douches, or the proper amount of Hunyadi or Carabana 
water, or some other mild saline, may be required. Diu- 
retics and demulcents are usually advisable, and are 
often of great benefit. Natural mineral waters should be 
used exclusively, the variety depending upon the case ; 
in general, Poland or Peperill will be satisfactory. If 
there is a gouty or rheumatic diathesis, a lithia water ; if 
there is an ansemic condition or an associated chronic 
diarrhoea, some one of the ferruginous or ferro-arsenic 
waters should be substituted. In many cases, slippery 
elm, Triticum repens, hops, blackberry tea made from 
blackberry jelly, or barley water, act equally well, if 
not better. Gooseberries eaten in moderation will often 
cause mucus in the urine to disappear and at the same 
time produce a return of the acidity. Celery is often bene- 
ficial, but tomatoes generally aggravate bladder disorders. 
Many drugs have been given for physiological reasons, 
often with very beneficial results ; they serve to facilitate 
the action of the indicated remedy. Saline diuretics, such 
as Potassium citrate, in five to ten-grain doses, well 
diluted in water, may keep the urine neutral and bland. 
Salol, or Boric acid, in five-grain doses, by germicidal 
action, have been of much benefit. Uro tropin, in seven 
to fifteen-grain doses, dissolved in three ounces of water> 
after each meal, cannot be too highly commended. Pyuria 



CHRONIC CYSTITIS. 43 

often disappears under the administration of one-half- 
drachm doses of Sodium hyposulphite, well diluted in 
water, administered three times a day. When the urine 
is alkaline, offensive and decomposed, Benzoic acid, in ten- 
grain doses, six times a day, or Soda or Ammonia benzoate 
in the same doses, act well. Pyoktanin blue, one and a 
half grains in capsules, often produces rapid improvement, 
though it sometimes irritates the bladder ; this, however, 
can be avoided by the simultaneous ingestion of a few 
grains of Nutmeg. Naphthaline, two or three grains in 
capsules, four times a day, Chlorate of potash, Boric 
acid, etc., are also beneficial. When blenorrhagics are 
required, Sandal wood, Cubeba or Copaiva, in full doses, 
are of much service, but they must never be administered 
when fever is present. Mucus in the urine often dis- 
appears during the administration of grain doses of Tere- 
beue in capsules, or of Oil of Eucalyptus and Cubebs, five 
drops three times daily. Saccharine also gives good 
results. In many cases the removal of the predisposing 
cause, the antidoting by physiological means of the condi- 
tion present and the administration of the indicated rem- 
edy will cure. In other cases, however, local treatment 
will be required, either in the form of instillations or 
irrigations. Some practitioners prefer to commence with 
instillations, which are particularly indicated when the 
inflammation is located around the neck of the bladder 
and trigone. They should be applied with Bang's syringe 
sound, or through a catheter cut nine inches long, the eye 
of which when fully introduced will be located at the neck 
of the bladder, the selected solution being injected with the 
Taylor syringe. Nitrate of silver, in solutions of i to iooo 
to i to 20, is used almost universally, excepting in tuber- 
cular conditions, where it is especially unsatisfactory. Gen- 
erally it is best to commence with one of the weaker solu- 
tions and gradually increase to the stronger. From ten to 



44 UROPOIETIC DISEASES. 

sixty minims of the selected solution should be applied 
every two to six days, according to the reaction produced. 
When the cystitis is of the tubercular variety, Bichlor- 
ide of mercury, i to 4000 to 1 to 500, will be of benefit. 
Instillations also have a satisfactory effect upon the pus- 
producing bacilli. 

Irrigations have always been popular. The best and most 
satisfactory results are obtained by washing out the bladder 
by means of the Valentine hydrostatic pressure instrument 
without the catheter, or through a Marcy double current 
catheter connected with a fountain syringe, or, better yet, 
by Skene's apparatus, which consists of a soft rubber 
catheter joined to a piece of soft rubber tubing by means 
of a small glass tube, the whole being about two feet long, 
a small funnel inserted into the end of the tubing com- 
pleting the apparatus. It is used as an elongated catheter 
to empty the bladder of the urine ; after this the washing 
out is accomplished by pouring the solution to be used 
into the funnel, which is raised high enough to allow it to 
flow by gravity into the bladder ; the funnel is then low- 
ered to permit the fluid to escape. This process is repeated 
as often as necessary, using any desired quantity and press- 
ure; or after the catheter has been properly introduced, the 
bladder can be distended with the selected fluid with the 
author's modification of the Janet syringe, allowing the 
solution to evacuate itself while refilling the syringe. When 
ready for the operation the catheter should be introduced 
and the urine evacuated. The catheter, however, will re- 
main filled. If the bladder is empty the catheter should be 
filled before introducing it. The washing should be con- 
tinued until the fluid comes away clear. Great care should 
be taken to keep the catheter aseptic, and to lubricate it 
before introduction with L,ubri-chondriu or Carbolized Vas- 
eline. Full direction for the sterilization and care of the 
catheter will be found under urinary retention and under 



CHRONIC CYSTITIS. 45 

the care of the catheter in prostatic hypertrophy in the 
author's " Disorders of the Sexual Organs of Men." Some 
of the fluid should always be left in the bladder, the quan- 
tity being gradually reduced each time. 

All cases requiring catheterization do not necessarily 
need bladder irrigation. Even the presence of a small 
amount of mucus in the urine may not call for it. In 
some cases vesical douches produce great pain and distress, 
often of sufficient intensity to contraindicate their use. The 
bladder should never be over-distended sufficiently to cause 
pain. As a rule, it is best to commence with a warm solu- 
tion of salt, a teaspoonful to the quart, a saturated solu- 
tion of Boric acid, Thiersch's solution, or one of Sali- 
cylic acid, one-half grain, to the ounce of warm water, 
readily and quickly prepared by dissolving eight grains 
of Salicylic acid in one ounce of alcohol and adding 
this to a pint of hot sterilized water. Ernesty's aqueous 
Hydrastis, a teaspoonful to the quart of warm water, 
gives very satisfactory results. Solutions for bladder 
douches should be used at a temperature of 90 to ioo° F. 
Irritation of the bladder and the frequent calls to urinate 
may be palliated by the instillation into the deep urethra 
of a few drops of a 4 per cent, solution of Cocaine. 

It must be remembered that in chronic vesical disorders 
the bladder does not at first tolerate liquids of low specific 
gravity, hence the necessity of increasing their density. 
Dr. Gouley recommends the following : 

I* Hydrarg, Chlor. Corr gr. v. 

Ammonii Chlor., gr. xx. 

Spts. Gaultheriae, fl. 3ss. 

Acid. Boracic, 3*- 

Glycerinum, fl. 3 v iii- 

M. 
Sig. To y z fluid ounce of this solution add seven fluid ounces of 
warm water (no F.) and two and a half fluid ounces of Hydrogen 
peroxide. This ten-ounce solution is sufficient for four washings. It 
is unwise to commence irrigations at once or to repeat them too fre- 
quently. 



46 UROPOIETIC DISEASES. 

Soft water must always be used as the dilueut of bladder 
douches, as hard water chaps the interior of the bladder 
and produces unpleasant complications. After the bladder 
has become accustomed to irrigation, solutions of Nitrate 
of silver, i to 8000 to 10,000, Bichloride ol mercury, 1 to 
1000 to 40,000, Permanganate of potash, 1 to 400 to 
2000, Pix-creasol., r to 100 to 1000, or Creolin, 1 to 1000 
to 4,000, will be the most frequently required and in the 
order mentioned. Harrison warmly advocates neutral 
Sulphate of quinine, one grain dissolved in an ounce of 
water, to which solution, if cloudy, a drop of Muriatic acid 
is to be added. He also advises Quinine internally, as 70 
per cent, of it is eliminated by the kidneys within twenty- 
four hours after its ingestion. 

When the urine is alkaline and there is an excess of 
mucus in the bladder, with a tendency to the deposit 01 
phosphates and the formation of calculi, it may be eradi- 
cated by daily bladder irrigation with a solution of Citric 
acid, five to ten grains to the quart of warm water. A 
hypersensitive condition of the bladder wall may neces- 
sitate irrigations composed of Glycerine, two ounces, 
Bitartrate of soda, one ounce, water, sixteen ounces, or of 
a tablespoonful of L,ac Bismuth in six ounces of water, 
which by mechanically coating the mucous membrane of 
the bladder gives great relief. Vesical suppositories con- 
taining one grain of Opium, applied with the author's 
syringe emulsion carrier, may be required to quiet pain. 
No exact rules can be laid down as to the number of fre- 
quency of bladder douches. They must be administered 
according to the individual case, from two daily to 
one once a week. If they fail to give relief or cause too 
much pain, continuous urethral catheterization or perineal 
or supra-pubic cystotomy and permanent drainage may be 
required to give rest to the bladder and allow of proper 
local treatment. 



TUBERCULAR CYSTITIS. 47 



TUBERCULAR CYSTITIS. 



Etiology .—Tuberculosis of the bladder may be primarily 
local or depend upon invasion through haematogenic or 
lymphatic channels of the bacilli from remote lesions in 
the lungs, bones, etc. When the condition is local, the 
lesions may develop on any portion of the mucous mem- 
brane of the bladder; when ascending or descending, in 
origin they focus about the trigone and the base. Tuber- 
cular involvement of the bladder occurs, as a rule, between 
the fifteenth and the thirty-fifth years, though many cases at 
early and late periods of life have been reported. It is 
more prevalent in the male than in the female, which 
seems to indicate that the disease is most frequently as- 
cending, but pathological investigations point to a descend- 
ing origin. All departures from the normal status of 
health which are incentive to general tubercular invasions 
also predispose to tubercular cystitis. All patients suffer- 
ing from chronic inflammation of the uro-genital tract, 
whether simple, septic or gonorrhceal, who have a tuber- 
cular family history or for any reason become depressed in 
health, may develop this disease. It has been taught that 
infection may result from coitus, but complete investiga- 
tion generally proves this cause to be fallacious. 

Pathological Anatomy. — Following the initial inflam- 
mation there is infiltration of the mucous and sub-mucous 
tissues and the formation of miliary tubercules, which, like 
those found elsewhere, are composed of round cells, a few 
giant cells and some tubercular bacilli. The infiltration 
may become quite extensive. The tubercles undergo 
caseous degeneration, with accompanying destruction of 
tissue and the formation of tuberculous ulcers which are 
generally of irregular shape, large or small and shallow 
or deep, with bases and edges composed of indurated 
tubercular tissue. Small vegetations may spring from the 



48 UROPOIETIC DISEASES. 

surfaces of these ulcers, or they may become eucrusted with 
a deposit of the salts of the urine. 

Clinical History. — Increased frequency in the calls to 
micturate is generally the first symptom, and is often 
overlooked for a considerable period. It is due to the 
congestion of the inner layer of the bladder wall, the result 
of invasion by the tubercular bacilli. As the disease prog- 
resses, the desire to urinate increases, and in time it may 
become almost incessant. It is generally most marked 
after meals and at night, though there are many ex- 
ceptions. 

Hsematuria is also an early manifestation ; it may be 
the earliest symptom. The amount of blood varies greatly. 
At first there is only sufficient oozing from rents in the 
congested blood vessels of the mucous membrane to tint 
the urine and give it a rose-red or pinkish appearance. 
The last few drops of the urine voided may be quite 
bloody. Occasionally the haemorrhage is profuse, owing 
to the rupture of a large vessel. The bleeding may 
be constant or interrupted. It may disappear for a long 
interval and return again without apparent cause or after 
some slight exertion, etc. 

Pain is noticed only during micturition, it is burning 
stinging in character, referred to the deep urethra and 
the anterior portion of the penis ; frequently it continues 
for some time. If cystitis develops, the pain in the bladder 
may become severe, agonizing and continuous, and if from 
any reason clots, etc., lodge in the urethra marked 
tenesmus follows. A deep, dull pain behind the scrotum 
and in the supra-pubic region, increasing with over-dis- 
tention of the bladder and relieved by evacuation of the 
urine, is often present. 

At first the quantity of urine is sometimes increased. 
It may be apparently normal, clear and pale or slightly 
tinged with blood. When pus appears, if the reaction con- 



TUBERCULAR CYSTITIS. 49 

tinues acid, the urine will be slightly dim, but when it be- 
comes alkaline the urine will be dark and very cloudy. 
The color depends upon the quantity of blood present, and 
will vary from a slight pink tint to a deep dark red. The 
urine may contain clots and small pieces of necrosed tissue 
with gritty particles, pus and blood cells, as well as uric 
acid, urates and oxalates. Epithelial cells from the bladder 
and the pelves of the kidneys and renal casts are often 
present. Tubercular bacilli may be found in the urine 
before it becomes purulent, but rarely afterward. The 
smegma bacillus, as well as other micro-organisms de- 
pending upon the antecedent conditions, develop rapidly 
in urine which is a little old and cannot be readily differ- 
entiated by staining and microscopic examination from 
the tubercular bacillus ; therefore, fresh urine must always 
be examined. 

Fever, with its characteristic evening exacerbation, is 
rarely absent. There may be chills with the onset of sup- 
puration. 

Diagnosis. — Tubercular cystitis should always be sus- 
pected in patients between fifteen and twenty-five with a 
history of frequent micturition and slight hsematuria, par- 
ticularly if they have a tubercular family history and on 
examination tubercular nodules or other evidences of 
tubercular invasion are found in the epididymus, the vas 
deferens, the prostate, the lungs or in other organs of the 
body. Hematuria from vesical calculus is relieved by 
rest; repose and the horizontal position aggravate the 
bleeding in tubercular cystitis. Tumors of the bladder 
occur generally in middle or advanced age; they bleed 
profusely, but there is no increase in the frequency of the 
calls to micturate. Chronic cystitis is usually easily dif- 
ferentiated by the history ; it may be difficult when due to 
gonorrhoea. Tubercular cystitis may be differentiated 
from tuberculosis of the kidneys or ureters by the fact 
4 



50 UROPOIETIC DISEASES. 

that the former is slow in development and the latter very 
rapid. In women, hsematuria is generally the first symp- 
tom, and an accompanying polypoid growth is often found 
around and within the meatus urinarius. 

Prognosis. — The course of tubercular cystitis is chronic, 
with acute exacerbations from various causes. Often the 
disease will slumber or even disappear, only to return 
again after some slight cold or over-exertion. The gen- 
eral health, as a rule, remains unaffected until a late 
period; the disease is not incompatible with long life. 
Severe haemorrhage which threatens life may occur, though 
happily it is exceedingly rare. The prognosis, when 
everything is considered, is grave ; general tubercular in- 
volvement, abscesses, etc., causing general sepsis and death 
may result. 

Treatment. — Until from extension of the tubercular 
process cystitis develops, instrumentation of all kinds is con- 
traindicated, as the most serious consequences may ensue 
and a mild and slumbering disease become most painful 
and rapidly fatal. Therefore, until pus appears in the 
urine, treatment must be general — hygienic, climatic 
and medical. Diet must be plain, nourishing and non- 
stimulating ; bolting of food as well as over-eating must 
be interdicted. Fat food should be taken to the point 
of digestive tolerance. A dry, clear climate should be 
selected for residence and chilling of the surface of the 
body avoided. The bladder must not be allowed to be- 
come over-distended or the urine over-acid or alkaline. 
An occasional urinary antiseptic should be administered 
with the indicated remedy. When pus appears, the instilla- 
tion of ten to forty drops of a solution of Bichloride of 
mercury, i to 5000 to 1 to 2000, after the removal of 
residual urine (if there is retention) by catheterization and 
careful irrigation with a warm solution of Boric acid, 
every two to three days is often beneficial. More than 



IRRITABILITY OF THE BLADDER. 51 

four ounces of the selected solution should never be in- 
jected ; two are generally better. The Boric acid solution 
should return clear before the instillation of the Bichloride. 
The instillation into the bladder of 5 to 10 per cent, emul- 
sions of Iodoform in glycerine or a mucilage have been of 
seeming benefit. 

When general and local means fail, and the pain, haemor- 
rhage or frequency of micturition become unendurable, a 
cystotomy for drainage may be advisable. The perineal 
route, however, is to be avoided, as the resulting fistula 
generally becomes tuberculous. The supra-pubic affords 
relief and at the time of operation allows of the removal of 
growths and the application of Iodoform, Balsam of Peru, 
etc. Guyon's double drainage tube should be used and 
the bladder washed three times a day with a normal saline 
or Thiersch's solution. 

The remedies symptomatically indicated are given in 
chapter on vesical therapeutics and must be prescribed 
according to the individual cases. 

IRRITABILITY OF THE BLADDER. 

Etiology. — This condition is frequently associated with 
or caused by some perverted sexual habit, a concen- 
trated condition of the urine, a gouty or strumous dia- 
thesis, or by reflexes from a stone in the bladder, prostatic 
disease, rectal, uterine or ovarian lesions, taenia, vege- 
tations, growths, congenital or acquired contractions at 
the meatus urinarius, etc. 

Clinical History. — The development of an irritable con- 
dition is slow ; it may begin with an inflammatory process 
and disappear with the subsidence of the inflammation. 
There is frequent desire to urinate, usually without 
burning, smartings, or tenesmus; these may, however, be 
present. Micturition is not at all times satisfactory, and 
the desire may return again in a few minutes, especially 



52 UROPOIETIC DISEASES. 

if the patient is worried, mentally depressed, or exposed to 
a damp, cold atmosphere. On the other hand, if pleas- 
antly engaged or somewhat exhilarated by drink, hours 
may pass without the least inconvenience or desire; sleep 
is not disturbed. 

The urine may be passed slowly ; sometimes there is a 
short wait before the act, caused by spasm of the muscles 
of the membranous urethra; at other times the stream 
will start with a spurt. It is generally clear and free from 
pus, epithelium or mucus, acid in reaction and contains 
crystals of amorphous phosphates, urates and oxalates. 

Erections may be frequent or absent, with some uneasi- 
ness around the scrotum, and especially in the rectum; 
possibly a little irritation is experienced at night and 
sometimes dull, dragging pains with disturbance of the 
bowels. 

The passage of a full-sized bulbous bougie may give evi- 
dence of spasmodic constriction in both the membranous 
and prostatic portions of the urethra ; it may produce faint- 
ness, desire to urinate or a seminal emission. On removal, 
a trace of blood is sometimes noticed on the instrument, 
but its passage usually affords marked relief for a few days, 
although slight burning may accompany the next act of 
micturition. 

Treatment. — The cause should be removed, the general 
health and morale of the patient improved and outdoor em- 
ployment recommended. The passage of a full-sized steel 
sound every fourth day has cured many cases. Applica- 
tions to the prostatic urethra, by means of the Bang's 
syringe sound, of two or three drops of a solution of 
Nitrate of silver, one to ten grains to the ounce of water, 
are sometimes required. In the female, growths at the 
meatus urinarius can be removed by the button-hole oper- 
ation, or more easily by snipping off the growth, including 
a portion of the mucous membrane about the base, and 



URINARY INCONTINENCE. 53 

cauterizing with Nitric acid or Pyrozone, 25 per cent. The 
condition, however, is often cured by the following reme- 
dies : Nux vomica, in the gouty and strumous ; Belladonna, 
Ferrum aceticum or Ferrum phosphoricum if there is con- 
gestion ; Rhus aromatica, Hyoscyamus, Buchu, Kquisetum, 
etc. 

URINARY INCONTINENCE. 

This condition is of frequent occurence and may be the 
result of many disorders ; it is a symptom and not a dis- 
ease. It is frequently met with in young children and 
women, and may be caused by a hearty meal late at night, 
the drinking of water before* retiring, neglect on the 
part of the parent to see that the child urinated before 
going to bed, or reflex from a narrowed prepuce, the ac- 
cumulation of smegma behind the glans penis, or adhe- 
sion of the hood of the clitoris. 

It is often the first symptom of Bright's disease; it may 
indicate stone in the bladder, worms in the rectum or 
vagina, or arise from spinal irritation, diminished activity 
in the vesico-spinal centre in the lumbar part of the cord, 
epileptic conditions, chorea of the bladder, etc. Vesical 
chorea may be accompanied by other choreiform move- 
ments. 

Clinical History. — Nocturnal enuresis is usually due to 
exaggerated action of the muscular coat of the bladder. 
The compressor urethrse being off guard, or having lost its 
tone, does not control the discharge of the contents of the 
viscus. It is not necessarily continuous, and may be in- 
termittent or occur only after exposure to cold or from 
fright. In the adult it is usually the result of retention 
of urine and consequent overflow. It may be due to 
want of tone in the muscular coat of the membranous 
urethra, hypertrophy of the bladder, or irregular develop- 
ment of the prostate gland, so that the bladder overflows 
when filled beyond a certain point. 



54 UROPOIETIC DISEASES. 

Treatment. — The cause should, if possible, be removed, 
and hearty meals and drinking late in the evening 
avoided. Children afflicted with enuresis should be 
awakened and taken up during the night to urinate, and 
above all should not be scolded or whipped. A light 
should be kept burning in the room to make the sleep less 
profound. When the urine is over-acid, an alkali should 
be given ; if ammoniacal, Benzoic acid will be indicated. 

Remedies: Causticum, Pulsatilla, Gelsemium, Hyos- 
cyamus, Rhus aromatica, Nux vomica, Stramonium, Equi- 
setum, Triticum repens, Terebinth, Cina, Santonin, Agari- 
cus, Cimicifuga, Mullein oil, etc. Phenacetin and Anti- 
pyrine may, in doses of one to five grains at bed-time, in 
hypertrophy of the muscular walls or atony of the com- 
pressor urethral, relieve vesical irritability and enable the 
patient to retain the urine for some hours. 

Electricity has been recommended in its various forms, 
the latest being cauterization of the prostatic urethra with 
the Freudenberg-Bottini cauterizer. ' In using the gal- 
vanic current, a broad, flat pad attached to the negative 
pole is placed over the lower dorsal or lumbar region, 
a button electrode connected with the positive pole 
applied to the perineum, and a mild current given daily 
or every second day. Or, the positive pole may be 
applied to the lumbar region and the negative over the 
bladder or in the urethra by means of a small urethral 
electrode. The farad ic current has also been used to 
advantage. 

Brandt reports a number of cases in females cured by 
massage of the bladder : The patient should stand lean- 
ing slightly forward with the hands against the wall, 
while the masseur makes a rapid, springy percussion 
down both sides of the spine with the closed fists. Be- 
ginning at the lumbar region, he strokes the parts down- 
ward over the buttocks three or four times with the 



STRANGURY OR VESICAL TENESMUS. 55 

open hand. The patient then assumes the dorsal posi- 
tion, and the operator standing at her side places his 
hands with the ulnar surfaces approximated and the tips 
of the fingers directed toward the pubes and pushes 
them deeply into the region at the side of the bladder, 
as if to grasp it, and makes a vibratory movement with 
each hand as if about to remove the organ. This is 
repeated three times. The index finger of the left hand 
is now introduced into the vagina and flexed obliquely 
so as to partly encircle the neck of the bladder. The 
right hand grasps the left wrist to make it firm, and 
the index finger is made to vibrate against the neck, 
pressing it firmly against the pubes. This is done three 
or four times with the left and repeated with the right. 
The patient should bring the knees and heels together, 
raise the pelvis and support herself on heels and shoulders 
and repeat the movement a second time. The operator 
now places his hands on the inner side of the patient's 
knees and forces the limbs apart while she resists the 
movement. He next tries to prevent her closing them. 
This is repeated four or five times, and finally the tapote- 
ment ot the lumbar region is again performed. In chil- 
dren and males the finger is introduced into the rectum. 
When incontinence is due to overflow from retention, the 
treatment is the same as advised for that condition. 

STRANGURY OR VESICAL TENESMUS. 

This consists of an uncontrollable, agonizing, straining 
and contraction of the neck of the bladder, and occurs as 
a symptom in many acute diseases ; it may be of neuralgic 
or inflammatory origin. 

Treatment. — The electro-static current applied to the 
spine and hypogastrium or deep urethral instillations of a 
4 per cent, solution of Cocaine as well as a i per cent, 
solution of Nitrate of silver have given immediate relief. 



56 UROPOIETIC DISEASES. 

Camphor, in repeated doses, usually acts satisfactorily; 
Cantharis, Belladonna or Hydrangea, and in the female 
Copaiva, Eupatorium and possibly Apis or Capsicum may 
be required. 



CHAPTER IV. 

URINARY RETENTION. 

Retention of urine, though classed as a disease, is simply 
a symptom. It implies inability of the patient to empty 
the bladder. It may be voluntary or involuntary. 
Voluntary retention is often practiced by children at play 
and by young girls and women from inconvenience or pro- 
crastination ; in time it may produce atony of the bladder 
muscle and terminate in true retention. Involuntary re- 
tention may be caused by congestion, acute inflammation 
or traumatism of the bladder walls, by prostatic enlarge- 
ments, strictures of the urethra, or by obstruction of the 
vesical opening of the urethra by a calculus, a blood clot, 
a new growth or a foreign body. It may also be produced 
by paralysis or inco-ordination of the bladder muscles. 

Pathology. — Acute over-distension of the bladder from 
retention of urine if not immediately relieved is followed 
by congestion, inflammation, with extravasation into its 
walls, etc., and ultimate desquamation of the vesical epithe- 
lium. This solution of continuity of the epithelial lin- 
ing, which normally prevents urinary absorption, allows the 
urinary poisons and bacteria entrance into the general sys- 
tem through the lymphatic and blood channels. If micro- 
organisms are introduced from without, cystitis, etc., rapidly 
follow. Over-distension of the bladder by urine not only 
induces congestion, of its walls, and of the prostrate, but 
it also allows the backward flow of the urine from the 
bladder through the ureters to the pelvis of the kidney 
and involves these portions of the urinary tract in the 
congestive process. Paralysis of the detrusor muscle of the 
bladder occurs to a varying degree, often to the extent of 



58 UROPOIETIC DISEASES. 

making the viscus absolutely flaccid when the urine is 
evacuated. The muscular fasciculi of the bladder may be 
paralyzed and a trabiculated condition result. The perito- 
neum and adjacent abdominal viscera also are frequently 
congested. 

Chronic retention of urine produces, congestion of the 
bladder and renders it susceptible to bacterial infection. 
If the over-distension is of sufficient degree, the other 
uropoietic organs become involved. As the condition pro- 
gresses, the vesical wall becomes dilated and loses its 
tonicity, and there may even be a paralysis. In many 
cases there is a primary hypertrophy, followed in time by 
dilatation and sacculation, with subsequent dilatation and 
disease of the ureters, pelves of the kidneys and even of 
the kidneys themselves. The renal lesion due to the con- 
gestion first causes polyuria and later anuria. In nearly 
all cases of chronic retention, there is an associated 
cystitis produced by infection from without through 
careless instrumentation, or from within by infection from 
the bacilli coli communi, etc. 

Clinical History. — Retention may develop suddenly or 
insiduously, and be complete or incomplete. Complete 
sudden retention produces pain in the region of the bladder 
accompanied by frequent unsuccessful agonizing painful 
attempts to micturate, which increases in severity until the 
urine is evacuated. Tenesmus becomes constant and har- 
assing, with tenderness over the vesical region. If the re- 
tention is not relieved, a globular-shaped fluctuating tumor, 
dull on percussion, will fill the bladder region and in some- 
cases extend as high as the umbilicus. 

When the retention comes on insiduously, it may de- 
velop so slowly and painlessly that it may not even be 
suspected until a physical examination reveals its existence. 
The earliest symptom is an increased frequency in the calls 
to micturate, the urinary stream being diminished in 



RETENTION FROM CONGESTION OR INFLAMMATION. 59 

volume and force. When the residual urine exceeds four 
to six ounces, the increased frequency of micturition and 
the continued tension of the bladder walls produce a 
chronic congestion, which encourages urinary fermentation 
and the development of cystitis. 

RETENTION FROM CONGESTION OR INFLAMMATION 

This is generally the result of a gonorrhceal invasion ot 
the prostatic urethra, the development of a prostatic ab- 
scess, traumatism of the parts or the application of an 
irritating injection, particularly when the urethra or pros- 
tate is damaged. 

Treatment. — If the prostate is hot, swollen and sensi- 
tive from congestion alone, hot general baths, hot rectal 
douches with the Kemp prostatic cooler, rectal supposi- 
tories containing extract of Opii, one grain, and extract of 
Belladonna, one-quarter grain, every two hours, with 
Aconite, Arnica, Belladonna, Gelsemium or Veratrum 
viridi, as indicated, will generally give relief. If the con- 
gestion is not relieved in a few hours catheterization must 
be instituted. Prostatic abscesses must be opened by in- 
cision through the perineum and dressed surgically. If 
the retention is due to congestion and spasm of the 
urethra, and the general means already given do not 
afford relief, catheterization with a solid silver catheter of 
proper size will be required. Etherization may be neces- 
sary, though local anaesthesia with a 2 per cent, solution 
of Cocaine or Kucaine will generally be sufficient. 

RETENTION FROM PROSTATIC ENLARGEMENT. 

This is the one symptom of prostatic hypertrophy which 
is of paramount importance. The condition may be due 
to a gradually increased resistance to the exit of the urine 
by the development of a collar-like band around the vesi- 
cal neck, with elevation of the mouth of the urethra, which 



60 UROPOIETIC DISEASES. 

leaves a pouch in the bladder behind and below it; to 
obstruction to exit by the overgrowth and projection 
backward into the bladder cavity of the so-called middle 
lobe ; to the elongation of the prostatic urethra by the 
overgrowth of the lateral lobes of the prostate, and a nar- 
rowed and tortuous condition of the canal for the same reason. 
Enlargement of the prostate can readily be ascertained by 
rectal examination. Retention may also be produced by 
hypertrophy of a muscular band or posterior fasciculi of the 
prostatic urethra without special enlargement of the pros- 
tate, i. e., not sufficient to be recognized by rectal exami- 
nation. The pathological growths cause weakness of the 
bladder wall in general, though there is often an associated 
hypertrophy of special muscular fasciculi producing perma- 
nent ridges which project into the vesical cavity, which in 
time undergo degeneration. Provided cystitis does not 
develop, urinary retention from prostatic obstruction until 
it exceeds four to six ounces produces practically no 
symptoms except a little increased frequency in the calls 
to micturate and the necessity of evacuating the bladder 
once during the night or early in the morning. In fact, 
urinary retention from prostatic hypertrophy may develop 
so insiduously that it entirely escapes the notice of the 
patient. As retention increases, the bladder becomes 
greatly over-distended and may even reach to the umbili- 
cus. The ureters and the pelves of the kidneys become 
involved, and even changes in the kidneys are produced, 
which cause polyuria and anuria, with an accompanying 
and consequent gastro-intestinal derangement. Increased 
frequency of micturition develops in proportion to the 
dilatation of the bladder, the calls being more frequent at 
night, and the volume of the stream being diminished or 
even stopped by pressure ; the condition finally termi- 
nates in incontinence of urinary retention. When cys- 
titis is added, the state of the patient is truly pitiable. 



RETENTION FROM PROSTATIC ENLARGEMENT. 61 

The history of the case, the presence of an enlarged 
prostate verified by rectal examination, a tumor occu- 
pying the bladder region, often extending towards and 
even reaching to the umbilicus, and the length of the 
urethra increased to ten or eleven inches, with the residual 
urine obtained by catheterization immediately after mic- 
turition, makes a clear, diagnostic picture. 

Treatment. — Complete retention from prostatic obstruc- 
tion always requires surgical relief. If it is incomplete, 
palliation may be instituted for the time being. Catheter- 
ization, if possible, is the ideal method. It must be per- 
formed under strict antiseptic methods or bacterial infec- 
tion of the bladder may follow the immediate relief af- 
forded. 

Before catheterization is commenced, the external parts 
and the hands of the operator must be cleansed and ren- 
dered aseptic, and sterilized towels placed about the penis. 
A No. 1 6 F. soft rubber catheter, previously lubri- 
cated with sterilized Vaseline or Lubri-chondin, should 
be introduced into the urethra and the canal douched 
through the catheter with a warm saturated solution of 
Boric acid, conducted from a sterile water bag by means 
of a piece of tubing. If this catheter cannot be intro- 
duced with gentle pressure, the following may be tried 
successively: (a) A Mercier catheter with one or two 
elbows; (b) an English catheter with a long curve 
formed by its contained stilet, or (c) the stilet or mandrin 
can be formed and covered by a small soft rubber catheter ; 
(d) a silver catheter, with a long prostatic curve; (e) a 
L/ohnstein filiform retention catheter ; (f ) a flexible olivary 
or conical catheter, if stricture of the urethra complicates 
the condition. If these means all fail, suprapubic aspira- 
tion, or puncture with the trocar and canula, will be neces- 
sary. Unless the retention is of short duration and the 
amount of urine less than twelve ounces, the bladder must 



62 UROPOIETIC DISEASES. 

not be completely evacuated at the first seance, for, if the 
retention is of long duration and the ureters and the 
pelves of the kidneys are involved, without accompanying 
infection, the sudden removal of the urine may cause renal 
or vesical haemorrhage with its consequent complica- 
tions. When infection is present, it ma3^ produce sup- 
pression of the urine with resulting uraemia and terminate 
fatally. When the quantity of urine retained exceeds 
twelve ounces, if it is sterile, a portion may be allowed to re- 
main to be gradually reduced by subsequent catheterization. 
When the urine is septic, after one-half to two-thirds 
of its volume has been evacuated, twelve ounces of a sterile 
saturated solution of Boric acid, at the temperature of the 
body, should be injected into the bladder, allowed to mix 
with the urine and then be withdrawn, and repeated until 
the urine returns clear, when twelve ounces of the solution 
may be allowed to remain in the bladder to be gradually 
evacuated by later instrumentation. Catheterization may 
be required from four to eight times daily. The bladder, 
after the first twenty-four hours, should never be allowed to 
contain at any one time more than twelve ounces of fluid. 
Generally the catheter can be discontinued after a week or 
two, though it must not be discarded altogether until the 
urine can be voided without straining, discomfort, etc. 
Sometimes catheterization can never be discontinued until 
operative measures have relieved the prostatic obstruction. 
Continuous catheterization is sometimes necessary when 
instrumentation is difficult, painful or produces much bleed- 
ing, when the urine is loaded with pus, ammoniacal, etc., 
or when the general system is blunted by feverish con- 
ditions. It gives rest to the bladder and facilitates vesical 
douching. It is particularly serviceable in the acute 
exacerbations of chronic cystitis accompanying retention. 
While it does not produce a reduction of the prostatic 
obstruction it relieves the congestion and irritation of the 



RETENTION FROM PROSTATIC ENLARGEMENT. 63 

parts. It is also useful in polyuria, hematuria, etc. It 
is instituted as follows: The selected catheter, 18 to 22 F., 
which may be of the English woven type, or a soft rub- 
ber with one elbow or self-retaining, is introduced and 
properly located by the effect produced upon the stream 
of urine by moving it forward and backward. The eye 
of the catheter should extend about one-half an inch 
into the vesical cavity. It should be tested by the injec- 
• ion into the bladder of four ounces of a warm saturated 
solution of Boric acid which should be completely re- 
turned, after which the urine should continue to drop from 
the end of the catheter. If introduced too deep it excites 
vesical pain and uneasiness. A small safety pin passed 
through the catheter one-half inch in front of the meatus 
prevents it passing deeper into the bladder, and threads 
fastened to strips of adhesive plaster applied to the 
sides of the penis, or by a bandage encircling the pel- 
vis, and separated from the glans penis by a small piece 
of borated gauze wound around the catheter holds it in 
position. The projecting end of the catheter must be 
enveloped in an antiseptic dressing. When it is desired to 
give the bladder complete rest, or when cystitis is present, 
the catheter is coupled by a small piece of glass tubing 
to a rubber tube of sufficient length to reach under the 
leg of the patient, across the bed and down to the bottom 
of a bottle at the side of the bed. . The bottle must be 
one- fourth full of a 10 per cent, solution of Carbolic 
acid to inhibit putrefaction and prevent infection, etc. 
Care must be given to the drainage, and if the urine 
should from any reason cease to flow the dressing should 
be rearranged. When the urine is aseptic and the bladder 
wall is in fair condition, or in the early stage of acute re- 
tention, the end of the catheter should be closed with an 
artery clip and the urine allowed to discharge only at 
stated intervals. If the bladder contains t>us or blood it 



64 UROPOIETIC DISEASES. 

should be irrigated with four ounces of a warm solution of 
Boric acid, a portion of which should be allowed to remain 
to be evacuated with the next discharge of urine. The 
catheter must be removed and sterilized every second day, 
and the urethral canal irrigated either with a warm satur- 
ated solution of Boric acid, Nitrate of silver, i to 8000, or 
Lloyd's Hydrastis, one drachm to two ounces of warm 
water, and the canal around the catheter flushed once or 
twice daily with one of the same solutions to prevent 
mechanical urethritis, which often results, and may, if 
neglected, cause abscess of the urethra. About a pint of 
the solution should be injected through the catheter, which 
must be withdrawn sufficiently to allow the fluid to 
pass into the urethra and flow along the side of the 
catheter and escape at the meatus. The penis must 
always be supported to prevent tension, pressure and 
irritation. Continuous urethral drainage can in many 
cases, be continued to advantage from three to eight- 
een days, and during the night and a portion of the 
day for many more. When from mechanical irritation, 
etc., continuous catheterization is unsuccessful, a supra- 
pubic or perineal cystotomy may be required. 

For treatment of incomplete retention from prostatic 
obstruction, see treatment of prostatic hypertrophy in the 
companion volume on " Disorders of the Sexual Organs of 
Men." 

RETENTION FROM SUDDEN OBSTRUCTION OF THE INTERNAL 
OPENING OF THE URETHRA. 

Sudden complete or incomplete retention may result 
from obstruction of the internal opening of the urethra 
by blood clots, tumors, calculi, etc. The diagnosis will 
be greatly facilitated by the previous clinical history. 
When due to blood clots, there will be a history of previous 
traumatism, haemorrhage and the passing of small clots, 



RETENTION FROM SUDDEN OBSTRUCTION. 65 

etc.; intermittent blocking of the urethra by clots, which 
soften in a short time, is characteristic. Acute retention 
from vesical calculus has a history of renal colic, frequent 
micturition and pain referred to the end of the penis. If 
a solid instrument is introduced, the calculus may be dis- 
lodged with a grating sound, and the urine voided as 
usual. Pedunculated growths have a history similar to 
blood clots; the introduction of a catheter to a point 
beyond the obstruction gives a ready exit to the urine, 
which possibly may be free from blood. 

Treatment. — For relief of retention resulting from cal- 
culus and tumors, see special chapters. Treatment for 
retention from blood clots will vary with the symptoms. 
If the patient is not in special pain, a hot bath, and a rectal 
suppositories of extract Opii, one grain, and extract of 
Belladonna, one-quarter grain, with irrigation of the urethra 
with a warm Boric acid solution may be all sufficient. If 
these fail, catheterization may be necessary. If the eye of 
the catheter becomes obstructed with blood clots, they can 
be dislodged by the injection of a drachm of a weak antisep- 
tic solution through the instrument, or the clots may be 
extracted by suction with the author's modification of the 
Janet vesical syringe. If catheterization is impossible, a 
suprapubic cystotomy will be necessary. Continuous 
catheterization is one of the most successful methods of 
treating hsematuria. 

Aspiration of the bladder may be required when the 
catheter cannot be introduced, as when the vesical mouth 
is plugged with a calculus, a stricture is present in the 
urethra, etc. It can be repeated a number of times daily 
for a considerable period without causing complications. 
The greatest antiseptic precautions are, however, neces- 
sary. The pubes must be shaved, washed with green soap 
and hot water, then with the Chloride of lime and soda 
preparation, followed by a solution of Bichloride of Mer- 



66 UROPOIETIC DISEASES. 

cury, i to 2000. The instruments and hands of the oper- 
ator must be rendered sterile. The skin is punctured 
with a tenotome about one-half an inch above the symphy- 
sis pubis in the line of the linea alba, the aspirating needle 
introduced through the puncture in a downward and 
backward direction into the bladder, and the urine 
evacuated on the lines already given. In withdrawing 
the needle, the suction of the aspirator must be continued 
or drops of the urine may be discharged into the needle 
tract and local infection, etc., will follow. 

RETENTION FROM PARALYSIS OR INCO-ORDINATION OF THE 
BLADDER MUSCLE. 

This form of retention may occur when the bladder 
and associated organs are free from defect. It may be 
caused by spasmodic closure of the sphincter vesicae, 
which may happen after a rectal or genito-urinary opera- 
tion, fracture of some bone, or other traumatism, from a 
constipated condition of the bowels, etc. In shock, trau- 
matism, hysteria, neurasthenia, peritonitis, exhausting 
diseases, etc., it may in a degree be spasmodic, but is more 
often due to muscular atony and deranged reflexes; to 
injury to the brain mass, paralysis, locomotor ataxia, Pott's 
disease, etc., or to a failure of the detrusor, to loss of power 
of the bladder muscles, or loss of control or power of the 
sphincter. 

Treatment. — Acute cases of this class are often relieved 
by the administration of Hyoscyamus, Gelsemium, 
Aurum, Ignatia, Moschus, Valerianate of zinc, etc., with a 
large rectal enema and a general warm bath, the patient 
urinating while in the bath. Irrigation of the urethra 
with a warm Boric acid solution is sometimes successful. 
If for any reason irrigation is contra-indicated, a rectal 
suppository containing one-half grain of extract of Opii 
and one-quarter grain of Belladonna may relieve the 



RETENTION FROM URETHRAL STRICTURE. 67 

spasm and enable the patient to urinate. If these fail, 
the catheter must be used as already described, and the 
retained fluid in the bladder evacuated. If the disease is 
chronic, as in Pott's and other chronic diseases, the same 
care must be observed as already given under retention 
from prostatic enlargement. 

RETENTION FROM URETHRAL STRICTURE. 

That a stricture of the urethra is the cause of the reten- 
tion will be suggested by the history of a gonorrhoea, 
gleet, injury to the urethra or perineum, as well as by 
report of increased frequency in the calls to micturate dur- 
ing the day, with but little disturbance at night, the 
absence of prostatic enlargement and the presence of 
urethral narrowing, as demonstrated by the bulbous 
bougie, the immediate source of urinary retention being 
congestion and swelling of the obstructed part due to 
some excess in eating, drinking, exposure to atmospheric 
conditions, sexual excesses, etc. 

Treatment. — The administration of Aconite, Bella- 
donna, Gelsemium, etc., with a hot bath, hot rectal enema, 
hot stupes to the perineum and suprapubic regions, and 
an Opium and Belladonna suppository may give relief. 
If not, instrumentation will be indicated. Urinary reten- 
tion caused by a spasmodic stricture is often relieved by 
the introduction of a full-sized conical steel sound ; if this 
fails, the rat-tailed flexible or the filiform retention cathe- 
ter of Lohnstein may be successful ; or a whalebone fili- 
form guide can be introduced and retained which will 
allow the urine to be slowly expelled at its side. If these 
procedures all fail, a urethrotomy must be performed at 
once, or Cock's operation made and perineal drainage 
instituted. In many cases, suprapubic aspiration relieves 
for the time being. Aconite, Apis, Belladonna, Cannabis 



68 UROPOIETIC DISEASES. 

sativa, Cantharis, Copaiva, Cubeba, Gelsemium, Hyos- 
cyamus, Nux vomica, Opium, Pichi, Secale, Terebinth, 
etc., may be given as indicated. 



CHAPTER V. 
VESICAL TUMORS. 

Growths in the bladder may be benign or malignant. 
They usually commence as benign and later merge into 
malignant tumors. Primary malignant growths are un- 
common, but the primary and secondary together are much 
more common than the benign papillomata. Vesical 
tumors have as associate or concomitant conditions thick- 
ening and infiltration of the wall of the bladder, hydro- 
and pyo-nephrosis, suppurative pyelo-nephritis, etc. De- 
posits of the urine salts upon the growth sometimes produce 
a condition resembling a stone. Frequently a true stone, 
usually of small size, may be present with a bladder 
growth. Tumors of the bladder have a tendency to a 
mixed type, and while their general history is similar they 
have characteristic differences, so that the pathological 
nature of each deserves special mention. 

Papillomata occur more frequently in the male than 
in the female, and appear generally between the thirtieth 
and fiftieth years. There may be one or many, and are 
located, as a rule, at the base of the bladder, though they 
may be found about the trigone, in the ureteral regions, 
and sometimes in the posterior or lateral walls, but rarely 
elsewhere. They may be simple, short, multiple, branched 
or long slender villous growths of a reddish gray color and 
easily fractured ; sometimes they extend into the ureters or 
the urethra. These tumors may vary from one-half to 
two inches in diameter, have a short pedicle, or be sessile 
and cover a large area. They may be coronoid in form, 



70 UROPOIETIC DISEASES. 

the red vascular edges resembling a cock's cornb. They 
are composed of a connective tissue stroma, supporting a 
rich plexus of new-formed blood vessels, covered by epi- 
thelium and simply attached to the mucous membrane. 

Adenomata are rare. They are generally located near 
the neck of the bladder, and may extend into the urethra. 
They have been found in young children. They grow- 
rapidly and are soft in texture. 

Mucous polypi resemble polypi elsewhere. They may 
cause no symptoms whatever, though by continued growth 
they may over-distend the bladder. When small they may- 
give rise to symptoms simulating those of a calculus. 

Fibromata originate in the deeper tissues of the bladder 
wall, are covered by epithelium and may be sessile or 
pedunculated in contour. They occur only in the adult. 

Myomata are rare. 

Angeomata, Serous and Dermoid Cysts, have been re- 
ported, as well as fungoid growths produced by the 
Bilharzia hsematobia. 

Carcinoma as a primary lesion is exceeding rare, but as. 
a secondary growth it is comparatively frequent. It 
appears as a hard, friable, rounded or irregular swelling 
on a broad, firmly-attached and infiltrated base, having a 
granular, villous or ulcerated surface and indurated mar- 
gins. It is usually located at the base of the bladder or 
in the trigone, develops rapidly, and causes death in from 
six to twelve months. 

Sarcomata are uncommon, appearing before the fifth 
or after the fifty-fifth year. They may be sessile or 
pedunculated, and they vary greatly in size. 

Clinical History. — Sarcomata and myxomata occur 
principally before the fifth year, papillomata between the 
thirtieth and the fiftieth, and carcinomata between the 
fortieth and the sixtieth year. Symptoms of bladder 
tumors may be quite in evidence, or they may remain in. 



VESICAL TUMORS. 71 

abeyance during life and the growth be first discovered at 
the autopsy. The most prominent symptoms are hsema- 
turia, pain, frequency of micturition and the presence of 
a tumor. The amount of blood present in the urine varies 
greatly and bears no relation to the nature or size of the new 
growth. It may occur or discontinue without apparent 
reason, be continuous or intermittent, and give the urine a 
pink, red, brown or black color ; clots are present in vary- 
ing quantities. The urine may vary during the same day 
from normal to a deep black in color and contain clots. 
The percentage of blood present at each special discharge 
of bloody urine is greatest at the end of the act. 
Hsematuria frequently disappears for weeks, months or 
years, though, as the growth enlarges, the bleeding usually 
increases in severity. Profound anaemia, with all its asso- 
ciated symptoms may result, and death occur from syncope. 
Small as well as large clots, especially in an old or 
weakened bladder, may produce urinary retention, etc., 
though they are, as a rule, discharged after a little strain- 
ing. 

Pain is usually due to an associated cystitis ; it is referred 
to the hypogastrium and the neck of the bladder, and 
radiates down the penis, scrotum and thighs ; it is al- 
ways most severe at close of micturition. It may be 
caused by a portion of the growth being caught in the 
sphincter vesicae, the involvement of a nerve trunk in the 
inflammatory process, or to retention due to clots, a con- 
dition at times not only painful but alarming. 

Frequency of micturition and straining are sometimes 
present, especially in malignant conditions involving the 
trigone. The urine may be normal or be mixed with blood 
which imparts to it a pink or dark appearance. If there 
is an associated cystitis, the urine will appear whitish or 
opalescent and deposit a copious precipitate of phosphates, 
pus, clots of blood, shreds of mucous membrane and de- 



72 UROPOIETIC DISEASES. 

tritus. If albuminous from cystitis or nephritis the speci- 
fic gravity will be lowered ; if from the blood alone, it will 
be increased. In either case the albumen can be easily 
demonstrated to be present by the usual tests. When it 
is the result of suppurative inflammation or is of renal 
origin, the serum albumen w T ill exceed the globulin in the 
ratio of twelve to eighteen to one; in haematuria the 
globulin will exceed the serum albumen in the ratk 
of two and one-half to one to one-half to one. Pus, 
epithelial casts, urine salts and h) 7 aline casts are a pro- 
duct of the pyelitis and do not necessarily indicate a true 
nephritis. 

The physical signs of a tumor may often be demonstrated 
by abdominal, vaginal or rectal examination, by the use 
of the Thompson stone searcher or the cystocope. The 
initial examination must be made with the greatest of care 
and under strict antiseptic method. 

Diagnosis. — When induration or thickening of the 
bladder wall can be distinguished by digital examination, 
a malignant growth should be suspected. The diagnosis 
of bladder tumors in general depends upon the character 
of the haemorrhage, the physical signs of a tumor and 
cystoscopic examination. In females and in cases where a 
supra pubic opening has been made, digital examination 
is very satisfactory ; it is sometimes difficult to differ- 
entiate vesical from renal haematuria, though the pres- 
ence of blood in the urine as it issues from the ureters 
indicates a ureteral or renal source. A tumor in the region 
of the kidney or the presence of blood clots shaped like 
pieces of angle worms in the urine, with associated renal 
colic usually suggests a renal lesion, vesical clots being 
as a rule thick. There are cases, however, where both 
bladder and kidneys are involved, and also where no lesion 
is discovered. In the latter, the haematuria may be due 
to a varicose condition of the veins in the region of the 



VESICAL TUMORS. 73 

trigone ; in these cases the bleeding usually ceases after an 
-exploratory cystotomy. 

Prognosis. — Tumors of the bladder, if left to themselves, 
generally terminate fatally. Primary malignant growths 
develop slowly ; benign growths may exist for years with- 
out greatly undermining the health, but they must always 
be considered of serious import. Secondary malignant 
growths do not give favorable results when operated. 
Some successful removals of primary malignant tumors 
have been reported. Papillomata are usually removed 
easily ; they sometimes recur. 

Treatment. — In many cases, palliative procedures are 
advisable, and if the patient refuses operation may be the 
only form of treatment. Vesical irrigations of hot water 
with Alum, four drachms to the pint, fluid extract of 
Hydrastis, two ounces to the pint, equal parts of Pond's 
^Extract of Witch Hazel and warm water often give satis- 
factory results. 

Nitrate of silver irrigations, using solutions made from a 
standard solution of one grain of Nitrate of Silver to one 
drachm of distilled water, acidulated with a small quantity 
of pure Nitric Acid are often beneficial, commencing with 
•one composed of half a drachm of the standard solution 
to four ounces of warm water, the strength being gradu- 
ally increased every day or two until one or even two 
drachms are employed, regulating it so that no pain, in- 
creased frequency of micturition or straining follows the 
irrigation. Occasionally, when the solution of maximum 
strength has been in daily use for a considerable period, 
the bladder becomes irritable, and a weaker solution 
must be employed, but the treatment should not be dis- 
continued. About two ounces of the selected solution 
should be introduced into the bladder, retained for a 
few seconds, then allowed to discharge itself through 
the catheter while the syringe is being refilled. The 



74 UROPOIETIC DISEASES. 

douching must be repeated daily and continued without 
intermission for four, five, or six months, reaching the 
maximum strength of solution some five, six, or more 
weeks from the commencement of the treatment. If 
bleeding has ceased, as it should, the irrigation must be 
continued every other day for six months or longer, and 
afterwards every third day for a variable period. After 
this long course of treatment the application may be discon- 
tinue, even for a year, without any symptoms recurring ;, 
but should blood reappear in the urine the daily douching 
— commencing with the minimum strength and gradually 
increasing — must be again resorted too. In this way 
hsematuria, as well as the growth may be permanently con- 
trolled, and the patient may live in comfort for many years. 
The treatment at the start may occasionally increase 
the haemorrhage, but after several applications the blood 
lessens in quantity and finally disappears. Sometimes it 
never entirely ceases, being especially noticeable in small 
quantities at the time of catheterization, though every 
precaution may have been taken in introducing the instru- 
ment. It is apparently caused by the catheter damaging 
a growth situated near the neck of the bladder. In such 
a case, when the treatment is discontinued the haemor- 
rhage ceases, and the after-effect may be quite satisfactory. 

Clots of blood in the bladder are best left to them- 
selves; if they become lodged in the urethral month 
and cause overdistension of the bladder and pain, con- 
tinuous catheterization will be required. If haemorrhage 
threatens life, or pain and the other symptoms become 
agonizing, operative relief will be necessary. The bladder 
must not be allowed to become overdistended ; straining at 
stool and all forms of excess must be avoided, and a mild 
and non-stimulating diet selected. 

Surgical relief may be palliative or remedial. The 
palliative operations are drainage of the bladder by the 



VESICAL TUMORS. 75 

perineal or suprapubic route, the latter being preferable 
unless the growth occupies the anterior wall of the viscus ; 
in the female the vagino-vesical is to be preferred. 

Tumors of the bladder, if small, may be removed 
through the urethra by the lithocrite or the snare, or 
through a perineal opening, but these methods are un- 
satisfactory as portions of the growth may escape notice 
and be allowed to remain. For the suprapubic oper- 
ation, which is the one generally advised, the patient 
is properly prepared ; after anesthetization, the rectal bag 
is inserted and distended with from four to six ounces 
of water, and six to eight ounces of a warm solution 
of Boric acid are introduced into the bladder through 
a silver catheter, the latter remaining in position 
and being tied in the urethra by a soft rubber catheter 
around the penis. The patient is placed in the Trendelen- 
burg position. An incision four inches in length from 
the pubes upward in the median line is made through the 
skin, superficial and deep fascias. If it deviates from the 
median line, the fibers of the rectus abdominalis are 
separated by blunt dissection until the fascia forming the 
anterior boundary of the perivesical space is reached and 
divided, revealing the perivesical fat. The finger is 
introduced and the fat and peritoneum drawn up. The 
perivesical tissues are cut cleanly, not torn, the blood 
vessels ligated, the firm, white, globular wall of the 
bladder exposed, the end of the catheter found and proper 
silk guy sutures inserted. An incision two inches in 
length is made in the wall opposite the abdominal inci- 
sion, the finger introduced and the mucous membrane 
thoroughly examined. A glass speculum and head 
reflected light, or an electric light held in or connected 
with a pair of forceps, is used for ocular examination. 
If a growth is found, the vesical wall is temporarily 
sutured to the abdominal opening. If the opening is not 



76 UROPOIETIC DISEASES. 

of sufficient size, the attachments of the rectus abdominalis 
can be divided ; the pubes may be resected or symphysiot- 
omy performed. Small tumors may be drawn upward 
and removed by an eliptical incision through the base of 
the pedicle and the wound closed with catgut sutures 
which must be carried to the bottom of the excavation, by 
an ecraseur, or the mass may be removed by torsion. 
Resection of the bladder wall and implantation of the 
ureters into the intestine has been successfully performed. 
Curettement and cauterization of the growth have also 
been beneficial. 

If the growth is of considerable size and the bladder 
walls greatly infiltrated, drainage with proper packing 
especially in the male, will give the most benefit. After 
successful removal of bladder growths, the vesical wall may 
be properly closed, and continued urethral drainage insti- 
tuted for some three to six days with the expectation of 
good results, though supra-pubic drainage according to 
the Guy on method is advisable. For remedies symp- 
tomatically indicated see chapter on vesical therapeutics^ 
and section on hsematuria. Argentum nitricum, Arseni- 
cum, Geranium, Hamamelis, Ipecacuanha, Millefolium, 
Secale cornutum, Sulphuric ' acid and Thlaspi bursu pas- 
toris, have their reported cures. 



CHAPTER VI. 

FOREIGN BODIES IN THE BLADDER. 

Foreign masses other than calculi may enter the bladder 
through the urethra, the ureters find their way through the 
vesical wall from neighboring parts by ulceration, or be 
forced into it by traumatism. Those which enter through 
the urethra constitute the largest class and include pieces of 
catheters, filiform guides, slate pencils, whip cords, hair 
pius, pieces of grass, twigs of trees, gum, pencils, beads, 
etc. Among the objects which have passed through the 
ureters are blood clots, bullets, pieces of clothing, buttons, 
etc., these entered the pelvis of the kidney and escaped 
through the ureter into the bladder. Such substances 
may also be forced directly into the bladder through its 
walls. Foreign bodies from the rectum and vagina and 
other sources such as pieces of bone, fecal matter, teeth and 
hair from dermoid cysts, dressing forceps left during a 
previous surgical operation, etc., have by ulcerative process 
found their way into the bladder. 

Clinical History. — The urine may be unaffected, and 
if the foreign body is smooth no symptoms will appear; 
but if rough, pain is generally present, and cystitis with 
frequent calls to urinate and the discharge of a little blood 
at the end of the act will result. If the foreign body per- 
forates the wall of the bladder, a peri-cystitis will follow ; 
if it passes into the rectum it will cause proctitis, rectal 
tenesmus, etc., and if into the peritoneum or through the 
peritoneum into the intestines, peritonitis, etc., will result. 

Diagnosis. — This often depends upon the history, 



78 UROPOIETIC DISEASES. 

though it may require instrumental exploration or cysto- 
scopic examination to make a positive diagnosis. 

Treatment. — If the foreign body is soft or flexible, it 
can be removed with the lithocrite through the urethra. 
Hard, round bodies can be abstracted in the same manner 
either before or after they have been crushed. If the sub- 
stance cannot be removed easily, or it has been in the blad- 
der for a considerable period, a supra-pubic cystotomy will 
generally be the best method of procedure. 



CHAPTER VII. 
VESICAL CALCULUS. 

Contributed by William Francis Honan, M. D. 

A vesical calculus or stoue is a concretion of variable 
size formed by an aggregation of some of the solid con- 
stituents of the urine which have been precipitated in 
more or less crystalline form. The crystalline substances 
are arranged with some degree of regularity, and held 
together by an albuminoid frame-work derived from the 
mucus secreted by the urinary tract. The stone usually 
has its origin in a nucleus, which may be a large crystal, 
bit of tenacious mucus, blood clot, or some foreign body 
accidentally or intentionally introduced into the bladder. 
Upon this nucleus urinary solids are deposited, the dia- 
thesis of the patient and local conditions within the bladder 
determining their character and quantity. A calculus is 
classified according to its composition, if compound taking 
the name of the ingredient forming its bulk. Uric acid, 
Oxalate of lime, and Phosphates, in the order named, 
are the most frequent constituents of stone, but concre- 
tions of Xanthin, Cystin and Indican, though rare, are 
occasionally found. It is quite usual to find a stone com- 
posed of more than one ingredient; thus a Uric acid 
nucleus may be surrounded by a lamina of Oxalate of 
lime and the whole incrusted with a layer of Phosphates. 
There is great variety in size and weight, from a small 
gravel of a few grains to a mass weighing one or two 
pounds. The contour will depend largely upon the shape 
of the nucleus and effects of friction, for should there be 



80 UROPOIETIC DISEASES. 

more than one stone, or a single stone undergo spontaneous 
fracture, the multiple calculi or the fragments will show 
polished facets from mutual attrition. The surface of a 
calculus is usually rough, particularly in the Oxalate or 
lime variety, its knobbed or beaded appearance giving it 
the name of "mulberry calculus." The Uric acid stone 
is the most frequently met with, occurring, according to 
Roberts, in fifty per cent, of all cases. Sir Henry Thomp- 
son found that in 184 cases of stone, 122 consisted of Uric 
acid and Urates. It is hard, usually brownish and reddish- 
brown in color, and does not attain great size, except 
when its bulk is increased by the deposit of phosphatic 
encrustations induced by the irritation which its presence 
causes. The Oxalate of lime variety is small, round and 
very hard, and does not readily yield to crushing opera- 
tions. Phosphatic stones, usually found in old men, are 
large, grayish-white in color, chalky in consistency, and - 
friable. 

Etiology. — Age is an important etiological factor in 
the production of stone, the greater number being found at 
the extremes of life. In childhood and old age the ana- 
tomical arrangement of the genito-urinary tract is most 
favorable for its development. Hereditary gout and 
rheumatism furnish predisposing causes for formation of 
calculi. Life under poor hygienic conditions, which in- 
clude mal-assimilation of food and interfere with its. proper 
oxidation, favors the development of diatheses, which form 
a ground-work leading to the production of stone. There 
is no evidence that the continued ingestion of drinking 
water strongly impregnated with inorganic salts can per se- 
be capable of producing a calculus. Foreign bodies acci- 
dentally or intentionally introduced into the bladder and 
allowed to remain often become the basis of calculus. Such- 
instances as bits of broken catheter, hair pins, slate pencils,, 
are frequently met with occupying the centre of a vesical- 



VESICAL CALCULUS. 81 

stone. Any condition which causes retention of urine and 
its consequent decomposition favors the formation of con- 
cretions. Among these conditions are enlarged prostate, 
tight stricture, long and adherent prepuce, and tight 
meatus in boys. 

Symptoms. — Usually the first symptoms produced by 
the presence of a calculus are pain and increased mic- 
turition with more or less tenesmus. Pain varies in 
intensity and character, sometimes being dull, aching or a 
heaviness in the perinseum ; again sharp, lancinating or 
burning. It is seldom felt in the bladder, but often referred 
to the end of the penis or to the under surface of the urethra, 
a short distance posterior to the meatus. It is most 
marked during or at the completion of the urinary act, 
and is very severe in character. The constant contact 
of the stone with the already inflamed vesical neck pro- 
duces an irritation which finally becomes a marked inflam- 
mation. Lying on the back, particularly with the hips 
elevated, causes the stone to roll backward, and is usually 
a grateful position. Micturition occurs less frequently at 
night, but very often during the day when the patient is 
subjected to the jerking occasioned by riding or walking. 
This state of affairs is reversed in the patient with an en- 
larged prostate, who is obliged to urinate often at night, 
but is rather free from that annoyance when his mind is 
busily engaged during the day. The effect of motion, if it 
be violent, is to cause a traumatism of the already in- 
flamed bladder walls giving rise to hematuria, from the 
mere presence of blood in the urine tc 7esical haemorrhage. 
Reflex pains are felt in different parts of the body; testicles, 
hips, thighs and soles of the feet. If the stone is small it 
often rolls over the internal orifice of the urethra, and with 
a ball-valve action stops the stream at the height of the 
urinary act. This stoppage causes pain and straining, but 
both are usually relieved when the patient changes his 
6 



82 UROPOIETIC DISEASES. 

position, particularly when he lies down. Priapism is 
another symptom noticed particularly in young boys, often 
giving rise to masturbation. 

The symptoms above described constitute strong pre- 
sumptive evidence of the existence of a vesical calculus, 
but its presence is only positively determined when a 
metal sound is introduced into the moderately distended 
bladder and made to touch the stone, when the character- 
istic " click" is heard and a sensation imparted to the hand. 
This procedure, called " sounding," should be dignified as 
an operation, and the greatest care should be observed in 
the preparation of patient and instruments. 

Should there be an acute outburst of vesical symptoms, 
and it is usually at such a period that the physician sees 
the patient, rest in bed, diluents and remedies should be 
used until a quiescent state of the bladder is obtained. 
Serious consequences have followed the disregard of this 
very natural precaution, for the reaction following this 
manipulation, particularly in old men, is often very severe. 
Again, the error is made often in the opposite direction, 
and a patient treated for the indefinite condition, " catarrh 
of the bladder," stone never being suspected. It must be 
borne in mind that the above train of symptoms may exist 
without stone in the bladder, as certain neuralgic condi- 
tions due to causes difficult to discover often give rise to 
misleading suppositions. 

Before the operation the urine should be examined, 
and, according to its acidity, alkalinity or concentration, 
some pure water like Poland or Clysmic, or a mineral 
water like Iyithia, should be given in sufficient quantities to 
change the characteristics of the urine. If it be foetid the 
internal administralion of Salol, Boric acid, or Urotropin 
will tend to render it antiseptic. When sounding is to be 
performed the patient should be placed in the dorsal posi- 
tion, thighs and legs extended, upon a table or couch. 



VESICAL CALCULUS. 83 

Anaesthesia is usually necessary for the preliminary sound- 
ing, though the stone may be discovered with but little 
difficulty. But if the patient is old, and there is a prob- 
ability that manipulation will not be readily borne, prepa- 
rations should be made so that if stone is discovered an 
operation for its removal may take place immediately fol- 
lowing the sounding. 

The greatest care should be observed in the preparation 
of instruments which are to pass into the bladder. They 
should be surgically clean and all strong antiseptic solu- 
tions removed before introduction into the bladder by 
dipping them in sterilized water. Very annoying ure- 
thritis is often produced by the action of a strong germicide 
applied to the urethral mucous membrane from an instru- 
ment dipped in the same. The bladder should contain 
four or five ounces of fluid. A Thompson searcher is in- 
troduced and passed toward the posterior wall of the blad- 
der to the fundus, which is the most frequent situation of 
stone. The instrument is now withdrawn a short distance 
at a time, being rotated from side to side, so that its beak 
describes an arc of a circle and touches the base and lateral 
walls of the bladder at each turn. This manoeuvre, some- 
what varied, is performed many times. In a patient with 
enlarged prostate, the existence of the post-prostatic pouch 
is to be remembered, and during the withdrawal of the 
instrument, when its beak is about the centre of the blad- 
der, it is rotated through half a circle and made to explore 
this cavity. If these manoeuvres are followed by negative 
results, some water is drawn off, gentle efforts make the 
bladder partially collapse ; the patient may also be made to 
stand while the water is flowing off, when the stone often 
falls forward against the searcher. 

A stone may be present, but is not discovered, because of 
its being encapsulated by the walls of the bladder, or its 
surface covered with blood or mucus so that it gives no 



84 UROPOIETIC DISEASES. 

sound when touched. Again, mistakes may be made by- 
mistaking tumors encrusted with phosphates for stone, or 
the stone itself may be of such light specific gravity as not 
to give sufficient striking contact to be perceived by the 
sound. The old rule in surgery was never to operate for 
stone unless its presence could be determined when the 
patient was placed upon the table, no matter how recently 
it had been demonstrated. 

If the stone is found, contact of the beak of the searcher 
with its surface will tell whether it is rough or smooth, 
and the sound emitted by striking it will be sharp and clear 
if Uric acid or Oxalate of lime, and dull if phosphatic. 
Two stones are present, if, when the patient is quiet, rotat- 
ing the searcher from side to side produces a separate click 
on each side. The size of a stone may be often determined 
by passing a finger into the rectum and palpating between 
the searcher and finger. Again the searcher is introduced 
and its beak turned toward the side of the bladder where 
the stone was discovered and quietly rotated in that direc- 
tion while being withdrawn. When the stone is struck the 
collar of the instrument is pushed against the meatus, the 
tapping is continued, and when the click is no longer 
heard the end of the stone is reached and the distance be- 
tween the collar of the searcher and the meatus will rep- 
resent one of the diameters of the stone. After completion 
of the search the bladder should be washed with Thiersch's 
solution. 

Non-Operative Treatment of Stone. — The so-called 
"solvent treatment," the internal administration of cer- 
tain drugs and the injection into the bladder of sub- 
stances, all for the object of producing a chemical disinte- 
gration of the calculus, has from lack of success fallen into 
disuse. This method has existed from ancient times and 
has an interesting history, which is even now occasionally 
added to by the introduction of a new drug which in the 



VESICAL CALCULUS. 85 

laboratory seems to possess the requisite qualities, but 
which practically fails. Much can be done as a matter ot 
prophylaxis. A patient having an attack of renal colic 
should be taken in hand at once, and such methods em- 
ployed to rid him of the tendencies which ultimately suc- 
ceed in producing a calculus. Attention to diet is of first 
importance. Consideration must be given to the peculiari- 
ties of each patient. More frequently trouble arises from 
indulgence in the starchy, saccharine and oleaginous con- 
stituents of diet. Bread should be partaken of sparingly 
and lean meats, poultry, game, fresh fish, oysters and eggs 
should form the basis of the diet. The succulent vege- 
tables, such as lettuce, spinach, celery and fruits, may be 
taken with safety. Many beneficial effects follow the use 
of large quantities of pure water, like Poland, Clysmic, 
Bedford, Bethesda, etc. Milk is an excellent article of 
diet for such patients and may be given plain, skimmed, 
with lime water, peptonized or aerated with any of the 
carbonated mineral waters, and can be made to suit almost 
any phase of the patient's condition. Alcohol should, if 
possible, be interdicted or limited to white wine or a light 
claret. Exercise in the open air, not to be carried to the 
point of excessive fatigue or profuse sweating, should be 
advised. At this time remedies selected according to the 
diathesis possessed by the patient in conjunction with die- 
tetic and hygienic precautions will often produce very 
happy results. 

The Operative Treatment of Stone. — The factors in- 
fluencing the choice of an operation depend upon (i) age 
and general condition of the patient ; (2) state of the genito- 
urinary tract ; (3) the size and composition of the stone. 

The methods at our command are suprapubic lithotomy, 
perineal lithotomy, median and lateral, and litholapaxy. 
From exhaustive statistics, considering age, Cabot has 
shown that in children, from infancy to fourteen years, there 



86 UROPOIETIC DISEASES. 

is little to choose between litholapaxy and lateral lithotomy, 
slight advantage being in favor of the former, the supra- 
pubic operation being more dangerous than either. Bar- 
ling, however, in a series of 152 cases in children under ten 
years shows results markedly in favor of litholapaxy. In 
adult life the results decidedly favor litholapaxy, the danger 
of cutting operations increasing with age. In old age the 
rate of mortality is overwhelmingly in favor of litho- 
lapaxy, an operation extremely well borne at this time of 
life, notwithstanding the high mortality attending the per- 
formance of any variety of lithotomy. When, however, 
the calculus is complicated with a tumor of the bladder, 
when it is encysted, or too large or too hard to be crushed, 
lithotomy must be practiced. Litholapaxy is particularly 
contra-indicated when from a deep, unyielding stricture or 
enlarged prostrate the instruments could only be passed by 
using a dangerous amount of force ; also when there is 
reason to suspect that the nucleus of the stone is a foreign 
body not amenable to the lithotrite. The suprapubic, or 
high operation, is a procedure of much value. It is best 
adapted to large, hard or encysted stones, and though at- 
tended with more risk is undoubtedly growing in favor as 
its dangers grow less under improved surgical technique 
and antisepsis. It is well indicated in old men, in whom 
litholapaxy is impracticable. Also when it is expedient to 
remove a calculus and operate npon an enlarged prostrate 
at the same time. 

For a perineal lithotomy the patient is placed upon his 
back upon a narrow table which has been covered with a 
rubber cloth, so arranged that it will convey the blood and 
solutions to a pail placed beneath. At least three assistants 
are required, one to administer the anaesthetic, another to 
steady the knees and at the same time hold the staff, the 
third to use the sponge. If available it is well to use one 
of the several varieties of retentive apparatus to secure the 



VESICAL CALCULUS. 87 

knees and hold them apart. The rectum having been pre- 
viously emptied, the bladder washed out with a Boro-sali- 
cylic solution (Salicylic acid i part, Boric acid 6 parts and 
water 500 parts) the pubes and perineum are shaved, 
scrubbed and douched with a sublimate solution. The 
legs and thighs are thoroughly cleansed and wrapped in 
antiseptic towels. The rule in surgery that no matter how 
recently the stone has been discovered its presence must be 
demonstrated at the time of the operation is to be remem- 
bered. The fact that the staff strikes it when introduced 
shows the presence of the stone and also that the instru- 
ment has entered the bladder. About eight ounces of 
warm Boric acid solution are injected into the bladder, the 
staff introduced and passed to an assistant, who holds its 
handle vertically from the body and brings its concavity 
firmly against the pubic arch. The operator, seated in a 
chair of convenient height, is now ready for the operation. 
If lateral lithotomy is intended the operator steadies the 
integument of the perineum with his left hand and with 
the lithotomy knife makes an incision from a point to the 
left of the raphe, an inch and a quarter in front of the 
anus, downward and outward to a point about midway be- 
tween the anus and tuberosity of the ischium, but nearer 
the tuberosity. Care should be taken not to make the 
upper portion of this incision too deep so as to avoid 
wounding the bulb. The superficial structures being 
divided, the surgeon introduces the left forefinger into the 
wound and feels for the staff. When found the finger-nail 
is made to rest against the groove and the knife intro- 
duced. When certain that the point of the knife is in the 
bottom of the groove, it is pushed along until it enters 
the bladder. This fact is known by the gush of fluid 
which follows the opening of the viscus. The wound is 
enlarged by increasing the incision somewhat in a hori- 
zontal direction so as to cut through the thickest portion 



88 UROPOIETIC DISEASES. 

of the lateral lobe of the prostate. The right forefinger is 
now introduced into the bladder through the wound and 
the search made for the stone. If the incision is too small 
it may be further enlarged by the use of the probe-pointed 
bistoury. When the stone is located the staff is with- 
drawn and the lithotomy forceps introduced, using the 
finger as a guide. They are opened in the bladder, rotated 
and closed, when the stone will usually be found in their 
grasp. It must now slowly, and with a side to side move- 
ment, be withdrawn from the bladder in the axis of the 
pelvis. If possible fragmentation is to be avoided, but 
should it crumble in the jaws of the forceps, the several frag- 
ments must be removed by the use of a syringe and tube. 
There is usually some haemorrhage. Vessels in sight can 
be caught and ligated with catgut, hot water will usually 
stop oozing ; should it continue a square of antiseptic 
muslin is perforated in the centre, through the opening of 
which a stout rubber tube is passed and secured so that 
about three inches of it project, this makes the " chemise 
canula." The point of the tube is passed into the bladder 
and the umbrella portion is tightly packed with antiseptic 
gauze so as to make firm, equable pressure. The wound 
is covered with iodoform gauze. The skin in the imme- 
diate vicinity is anointed with iodoformized vaseline to 
prevent irritation from urine. The patient is placed upon 
pads of wood wool or salicylated paper. All dressings are 
to be changed when soaked with urine. Drainage tube is 
not to be used unless the urine is very foul. 

Median Lithotomy. — The patient is placed in the 
lithotomy position as before, and the staff introduced. 
The left index finger in the rectum locates the staff at the 
apex of the prostate. A straight bistoury with a double 
cutting point is made to transfix the perineum exactly in 
the raphe, half an inch in front of the anus and carried 
directly inwards to the groove in the staff at the point 



VESICAL CALCULUS. 89 

where the instrument is felt in the rectum. The knife is 
advanced slightly so as to enter the urethra and slightly 
incise the apex of the prostate. The knife is now made 
to cut forward and divide the membranous urethra. It is 
withdrawn, cutting its way out along the raphe, making 
an incision about one and a quarter inches long. A 
straight-grooved director is introduced and the staff with- 
drawn. The wound should now be dilated with the 
fingers and the stone extracted. Should sufficient dilata- 
tion not be obtained in this way the opening may be 
enlarged by making incisions downward into the prostate. 
This operation is only intended for small stones. 

Supra-pubic Cystotomy. — The anterior surface of the 
bladder is not covered by the peritoneum ; the latter is 
reflected from the former posterior to the point of con- 
tinuity of the urachus with the viscus. It is attached 
firmly to the summit and anterior surface of the bladder, 
but loosely to the abdominal wall at the point of reflec- 
tion, thus enabling it to accommodate itself to the various 
changes in size and position of the bladder. A space exists 
immediately behind and above the symphysis pubis not 
covered by peritoneum, which, by distending the rectum 
and bladder, can be increased to a considerable degree. 
The usual preparations for lithotomy having been observed, 
the patient is anaesthetized and the pubic region shaved 
and made antiseptic. A soft rubber bag or " colpeurynter " 
is introduced into the rectum. The bladder having been 
irrigated, seven or eight ounces of the Boro-salicylic solu- 
tion are carefully injected and allowed to remain, the penis 
being tied with a piece of rubber drainage tube. Filling 
of the bladder requires some caution, as rupture of that 
viscus has occurred during this procedure. The rectal bag 
is now filled with from ten to fifteen ounces of water. 
Some operators prefer to dispense with the rectal bag, 
placing the patient in Trendelenberg's position, when the 



90 UROPOIETIC DISEASES. 

bladder by its own weight separates the peri-vesical fold 
from the pubes. 

Bristowe has found from experience that the bladder is 
lifted up easier and more thoroughly with air. By his 
method air is injected with a syringe, which has between 
the bulb and injecting nozzle a glass tube filled with a 
filter of sterilized cotton. Either of the above methods 
having been employed an incision is made exactly in 
the median line, beginning about three inches above and 
stopping at the symphysis. A layer of loose tissue con- 
taining fat will have to be separated before the bladder 
wall conies into view. A small transverse incision is 
made in this tissue at the inferior angle of the wound and 
the forefinger introduced and pushed upwards, carrying 
before it the reflection of the peritoneum. The veinous 
plexus at the bottom of the wound should be pushed aside 
or divided between double ligatures, as it sometimes gives 
rise to troublesome haemorrhage. The bladder may be 
now secured by the introduction with a curved needle 01 
stout silk ligatures, one on either side of the proposed 
incision. The peri-vesical fold being held out of harm's 
way, the bladder is opened and the finger quickly inserted 
to find the stone. Its size being noted, the incision is 
enlarged to permit its removal by the forceps. The stone 
being removed, careful search is made to see if any bits 
remain which may have been broken off during removal. 
The bladder is thoroughly irrigated and a Guyon double 
drainage tube introduced and the wound packed with 
Iodoform gauze. The ends of the drainage tubes are 
joined by glass tubes to long lengths of rubber tubing 
which end in a large bottle at the patient's bedside. 
Sometimes the bladder wall is closed, using the inter- 
rupted L,embert suture. This should only be done in 
selected cases where primary union is expected, as urinary 
infiltration and septic infection are likely to occur. Many 



VESICAL CALCULUS. 91 

surgeons advocate the transverse incision (Trendelenberg's), 
as it affords an easier and freer opening into the bladder. 
The mutilation, however, is greater, shock more profound 
and great tendency to subsequent ventral hernia. It, how- 
ever, gives greater room for manipulation. 

An absorbent antiseptic dressing is placed outside of the 
tube and the patient kept on his side on an air cushion. 
This position favors drainage. The tubes can be removed 
about the fifth day. Boric acid in solution is used to irri- 
gate the bladder two or three times every twenty-four 
hours for the first few days. Sometimes it is advisable to 
close the upper third of the wound with sutures, and again 
splendid results have been obtained under conditions of 
improved technique by suturing the bladder and the greater 
part of the wound, leaving a small portion open for 
drainage. 

Litholapaxy. — This method consists of crushing the 
stone and removing the fragments at one sitting. Its in- 
troduction as a substitute for lithotrity by Bigelow, in 
1878, marked an era in surgery of the bladder. The in- 
struments proposed by the originator have stood the test 
of time in a highly satisfactory manner. It is an opera- 
tion not entirely free from danger, the patient often being 
subjected to long and trying ordeals before the desired re- 
sult is accomplished. 

The principal instruments employed are lithotrites, 
large and small, an evacuator with tubes of several sizes, 
catheters and sounds. Bigelow's lithotrite is perhaps the 
best. Its construction admits of easy introduction into the 
bladder through the dilated urethra, and the mechanism of 
the jaws prevents impaction. When the stone is crushed 
the fragments are best removed by the aid of Bigelow's 
evacuator, an instrument which perhaps has not been im- 
proved upon. The patient is to be prepared as for any 
other operation for stone, having partaken freely of some 



92 UROPOIETIC DISEASES. 

pure water, Poland, Clysmic, or Bethesda, for a couple of 
days before the operation, and the same effort made to 
render the urine bland by the administration of some of 
the antiseptics previously mentioned. The bladder should 
be washed out several times before the operation with a 
Boro-salicylic solution and the rectum emptied. The 
patient, thoroughly anaesthetized, is placed upon his back 
upon a table and the urethra dilated to a No. 25 to No. 28 
French scale. If necessary the meatus is cut to admit the 
instruments. Should strictures complicate they are to be 
divided or divulsed. Five or six ounces of fluid should be 
injected into the bladder and its outflow checked by tying 
a soft rubber tube about the penis. The lithotrite is now 
to be introduced. It is passed as a sound or catheter until 
the beak reaches the bulbous portion of the urethra. The 
lithotrite is now vertical, and the penis being drawn up- 
ward the obstruction offered by the triangular ligament is 
removed and the instrument slips into the membranous 
urethra. The handle is depressed gently between the 
thighs and the jaws glide along the prostatic urethra into 
the bladder. Should the beak of the instrument catch on 
the prostate the finger introduced into the rectum will 
guide it over the obstruction. Once in the bladder it is 
pushed to the posterior wall of the viscus. The male blade 
is now withdrawn until it reaches the vesical neck, then 
gently pushed back. Should this manoeuvre not be suc- 
cessful in catching the stone, the blades are opened again 
and turned on the side, then closed, this movement being 
repeated on both sides. The degrees of rotation should 
be varied and the movements repeated. If there is a post- 
prostatic pouch the opened instrument should search there 
with the beak directed into it. This last movement often 
catches the mucous membrane. If the patient's hips are 
raised the stone will often fall out of the pouch, or it may 
be dislodged by the introduction of the finger into the 



VESICAL CALCULUS. 93 

rectum. Again in extreme cases this post-prostatic pouch 
may be entirely obliterated by the introduction of a rubber 
colpeurynter into the rectum as suggested by Buckston 
Browne. 

With each new position of the lithotrite the male blade 
is pushed gently home. Should the stone be within its 
grasp the button is moved, the screw connected to hold the 
stone and the instrument rotated to the centre of the blad- 
der. If the mucous membrane has been caught the operator 
becomes aware of the fact at this moment. If it seems to 
be free the screw is turned slowly and gently at first to 
secure the stone safely in the jaws of the instrument, then 
sufficient force is applied to produce fragmentation. If the 
calculus is very hard it often slips from the jaws of the in- 
strument, particularly when it has not been caught in a 
favorable diameter. Again, if too hard, the screw cannot 
be turned. If soft the male blade advances evenly with 
each turn of the screw. After the stone is broken the 
fragments are picked up separately and crushed much in 
the same manner as was employed originally for the intact 
stone. With the small fragments it is not always necessary 
to put on the screw power, but they may be crushed by 
simply pushing the male blade home with the hand; this 
admits of greater rapidity in the disposal of the smaller 
fragments. When finally no more fragments can be found 
or when the patient's limit of endurance seems to have 
been reached by the length of the seance the jaws of the 
instrument are carried to the center of the bladder, the male 
blade pushed in and out several times to remove any im- 
paction, then screwed firmly into its fellow and the instru- 
ment carefully removed from the bladder. The evacuating 
tube of the lithotrite is now introduced, the shape and 
size depending upon the condition of the urethra. Usually 
a size equal to 28 or 30 French is selected, and if possible 
the straight tube should be employed, as it is easily turned 



94 UROPOIETIC DISEASES. 

in the bladder and affords a straight direct route for the 
passage of the fragments. When introduced it is attached 
to the bulb, which is held in the right hand while the tube 
is steadied with the left. The distal end of the tube is de- 
pressed so that the proximal opening is not buried in the 
detritus. Compression of the bulb at first, according to 
Bigelow, should be slight and rapid. This produces a com- 
motion in the bladder which sends the fragments rapidly 
through the fluid and they may be caught while in a state 
of momentary suspension. Sometimes the tube is blocked 
by a large fragment or a fold of mucous membrane covers 
the opening ; either may be dislodged by an abrupt forcible 
compression of the bulb. When the bladder walls are so 
caught it is an evidence that the solution is low, but may 
be replenished by dropping the rubber evacuating tube 
into the Boro-salicylic solution, closing the stop-cock to 
the bladder tube, thus filling the evacuator, then forcing it 
into the bladder. The last fragment is often difficult to 
find, or rather to remove, and it is often necessary to intro- 
duce a smaller lithotrite to crush it. When no more clicks 
can be heard or felt a sound is introduced and the cavity of 
the bladder carefully examined. A small tube, preferably 
a rubber catheter, is introduced and the bladder washed for 
the last time; . the fluid is allowed to run along the urethra 
to wash out any debris that may have lodged there. The 
patient is placed in bed and, if possible, should urinate 
naturally. A milk diet with frequent libations of water 
and Salol or Boric acid by the mouth constitutes the after 
treatment. A large soft catheter may be introduced several 
days afterwards to remove tenacious mucus or blood clots 
which may have collected after the operation. The pro- 
longed anaesthesia and the tendency to recurrence has 
militated somewhat against the popularity of this operation. 
The advocates of this precedure, however, ascribe any ill 
effects to the lack of skill and experience on the part of the 



STONE IN THE FEMALE BLADDER. 95 

operator ; this could hardly be said of such a skillful oper- 
ator as Reginald Harrison, who had 24 per cent, recur- 
rences in one hundred and one lithalapaxies. He advises 
that the bladder be washed frequently for weeks after the 
operation for the removal of any particles which may 
originally have escaped the evacuation. 

STONE IN THE FEMALE BLADDER. 

Stone in the bladder is not common among women, the 
large and easily dilatable urethra affording opportunity for 
small calculi to escape before their size is increased by 
further deposition of salts. The causes, symptoms and 
dignosis are practically the same as in the case of males. 

Treatment. — Dilatation of the urethra : This is to be 
accomplished with urethral or uterine sounds and then 
with the finger. When sufficient dilatation has been 
secured the stone, if small, may be removed with fore- 
ceps. If too large to remove in this way sufficient dila- 
tation is made to introduce a lithotrite and the stone is 
crushed. This is the method to choose in the majority of 
cases of stone in women. For evacuation, a short tube of 
larger calibre should be employed. Vaginal or supra- 
pubic lithotomy is to be employed when litholapaxy is 
impracticable. In the latter operation the patient is placed 
in Sims' position, a sound is introduced into the bladder 
and made prominent on the vesico-vaginal septum. This 
point is incised and the opening enlarged sufficiently to 
extract the stone. The wound should be kept open and if 
necessary the plan suggested by Emmet employed, that of 
stitching the vaginal and vesical mucous membranes 
together, and when the bladder has been sufficiently 
drained the opening is closed by the operation for vesico- 
vaginal fistula. As a rule, the wound made in the ordinary 
manner if left to itself heals spontaneously. 



CHAPTER VIII. 

CYSTOSCOPY AS APPLIED TO THE DIAGNOSIS 

AND TREATMENT OF THE URINARY 

DISEASES OF WOMEN. 

Contributed by George W. Roeerts, Ph. B., M. D. 

There exist certain differences between the urinary ap- 
paratus of the male and female members of our species, 
giving rise to practical variations in diagnosis, prognosis 
and treatment, which command a share of our attention. 
These differences are chiefly matters of anatomy, and 
while an exhaustive study elicits many minor dissimilari- 
ties, the principal and practical facts are few and quite 
easy of comprehension. 

Omitting then all matters of theory and those facts 
which, while they will doubtless become of value as our 
knowledge of genito-urinary disease increases, have not as 
yet bourne valuable fruit, we note first that the chief dif- 
ference between the urinary apparatus of man and that of 
woman is dependent upon differences in the genital appa- 
ratus of the two sexes ; and the most important of these 
differences is in the length, shape and anatomical structure 
of the urethra. The length of the male urethra is about 
9 inches, while that of the female urethra is only about 
ij^ inches. In the male its shape is that of a double 
curve while the penis is in the flaccid state, and a very 
marked single curve during erection. In the female its 
curve is single and only slightly marked. The male 
urethra is surrounded by rather tense structures, which 
limit its dilatability as well as its range of mobility. The 



CYSTOSCOPY. 97 

female urethra is much more dilatable and movable, par- 
ticularly in women who have bourne children. Another 
marked difference between the male and lemale urethra 
is the complicated system of ducts and glands which empty 
into the former and are absent in the latter. 

The female bladder also differs materially from the male 
bladder and, when compared with it, suffers from having a 
much less stable and efficient support, and as a result is 
easily placed at a mechanical disadvantage by rupture or 
relaxation of the perineal body which is so frequently the 
result of childbirth. 

The shortness and easy dilatability of the female urethra 
also permits easy infection of the bladder ; and this is es- 
pecially the case, when in addition we have a certain 
amount of prolapse of the bladder resulting in urinary 
stagnation of however slight degree. 

Now these same anatomical features which tend to pro- 
duce early and pronounced urinary lesions in women for- 
tunately present to the gen i to-urinary surgeon or the 
gynecologist many opportunities for examination, diag- 
nosis and treatment which are not as yet within easy and 
accurate command in the male. The short, easily dilatable 
and comparatively straight urethra affords an easy route 
for examination and treatment, where in the male the 
opposite conditions have compelled the exercise of great 
ingenuity and have only too often constituted insur- 
mountable barriers to accurate diagnosis. From these con- 
ditions it follows that it is useless, when dealing with 
women, to follow the complex methods used in diseases ot 
the male genito-urinary tract ; and on the other hand, 
necessary to consider means far more simple and happily 
far more satisfactory. The methods advocated and more 
or less successfully practiced by Griinfeld, Rutenberg, 
Nitze, Pawlik and others are either difficult of execution 
or restricted in their application ; one of the greatest ob- 



98 UROPOIETIC DISEASES. 

jections to them being the fact that they do not at the 
same time permit observation and manipulation within 
the bladder. On the other hand, the method of Kelly is 
easy of application, requires only ordinary surgical skill, 
permits us to see and work at the same time, and is there- 
fore of almost universal applicability. It is such a great 
advance over former methods that we will proceed at once 
to its consideration, having no hesitancy whatever in our 
belief that the older methods are of comparatively insig- 
nificant value. 

To aid in the accuracy of description of bladder lesions, 
as seen through the endoscope, certain landmarks must be 
noted and used in locating the lesions observed. The first 
and most important of these is the internal urethral ori- 
fice, for it is from this point that our investigation must 
begin ; and it facilitates one's mental picture of one's ob- 
servations to imagine oneself as standing at the internal 
urethral orifice and viewing the landscape presented by 
the mentally magnified bladder. Looking straight ahead, 
the eye meets a somewhat variable point on the posterior 
vesical wall, which has been described as " opposite the 
urethral orifice." With the patient in the knee-breast 
posture, we see above upon our right and about three- 
quarters of an inch within the internal urethral orifice the 
orifice of the right ureter, and in a corresponding position 
to the left the left ureteral orifice. Between these points 
extends a fold or sometimes a line of demarcation between 
the deeper red of the trigonum and the pale general vesi- 
cal mucosa ; while to either side, the intra-vesical portion 
of the ureter produces a rather obscure ridge leading out- 
ward toward the pelvic wall. 

Kelly has arbitrarily divided the bladder into quadrants, 
taking the internal urethral orifice for one pole and the 
opposite point upon the bladder wall for the other, and 
dividing the bladder by a vertical and again by a hori- 



TECHNIQUE OF CYSTOSCOPY. 99 

zontal plane. The base of the bladder being the most 
frequent seat of disease, is by far its most important por- 
tion, and therefore the ureteral orifices become important 
landmarks in locating strictly bladder lesions. The ap- 
pearance of these orifices varies greatly, not only in dif- 
ferent subjects, but in the same subject when viewed under 
different circumstances. Most frequently they appear like 
small transverse slits in the vesical mucosa, situated, if the 
patient is in the knee-breast position, at the top or upon 
the anterior surface of an ill-defined papilla. The slit is 
likely to be surrounded by a slight zone of redness, which, 
if not too pronounced, is not abnormal. Some of the 
more frequent variations in the appearance of these land- 
marks will be described as we consider the subject of 
ureteral catheterization. 

Just posterior to the trigonum, which is defined by the 
three orifices situated at its angles and by the inter-ureteric 
ligament, lies that portion of the bladder which is in con- 
tact with the upper part of the vagina, while just above it 
is the narrow strip which is in relation with the anterior 
surface of the cervix uteri. 

TECHNIQUE OF CYSTOSCOPY. 

As Simms in the use of his speculum took advantage of 
atmospheric pressure as influenced by the posture of his 
patient, so we, in examining the bladder and in working 
within its cavity, do the same; in fact, postural govern- 
ment of the intra-vesical air pressure is the key to success 
—is the only way by which we can at the same time see 
and manipulate within the bladder to a practical degree. 
No less important is proper illumination of the field at the 
same time that the bladder is distended with air. Both 
these conditions require special instruments and apparatus, 
as well as special precautions. 

Preparation of the Patient. — If the investigation is to 

LofC. 



100 UROPOIETIC DISEASES. 

be made under an anaesthetic, the patient is prepared ex- 
actly as for a minor vaginal operation. The bowels are 
thoroughly emptied ; the heart is examined ; the vulva and 
vagina rendered surgically clean, and the bladder evacu- 
ated. 

Anaesthesia. — If no anaesthetic is to be used, the patient 
can have her meals as usual ; but if ether or chloroform 
are to be administered, the stomach must be empty. As 
to the necessity of anaesthesia, it may be said that while it 
is not necessary in every case, it is highly desirable, and in 
some cases absolutely necessary. The posture is tiresome, 
the necessary urethral dilatation more or less painful, and 
the patient usually anticipates pain and is therefore likely 
to manifest a certain rigidity of the abdominal muscles 
which interferes with perfect distension of the bladder. 
The anaesthetic does away with all these factors, and per- 
mits that deliberation of thought and action by the oper- 
ator, which in the end is of the greatest value to his 
patient. 

Posture. — Either the knee-chest or the exaggerated 
lithotomy posture may be used with most patients, but 
there is sometimes difficulty, especially in very stout pa- 
tients, in getting successful distention of the bladder with 
the latter. The essential feature of either posture is that 
the pelvis shall be raised so high that the abdominal organs, 
falling, toward the thoracic cavity, act somewhat like a 
piston and produce a lessening of pressure within the 
lower segment of the abdomen. When this occurs there 
is a tendency for the abdominal wall to be depressed to fill 
the space, but due to obvious peculiarities of structure and 
location the bladder or rectum will respond much more 
readily than the thick muscular abdominal wall if we only 
overcome their sphincters and allow free ingress of air. 

Since the posterior abdominal wall is rigid, while the 
anterior, especially during anaesthesia, is flaccid, when the 



PLATE I. 




After Kelly. 




Adapted from Kelly. 



TECHNIQUE OF CYSTOSCOPY. 101 

patient is in the knee-chest position, we add to the " piston 
action" of the abdominal contents the weight of the an- 
terior abdominal wall, while in the dorsal position this 
opposes us ; considering then the knee-chest position to be 
the best one to be relied upon in the majority of cases, the 
patient is anaesthetized as usual, and then raised into the 
knee-chest position, as shown in the accompanying illus- 
tration, Plate I. The whole procedure may be very 
greatly facilitated by use of the apparatus described by 
Dr. Clement A. Penrose, in Johns Hopkins Hospital Bulle- 
tin, of November, 1899, although no special apparatus is 
absolutely essential. 

Asepsis. — The practice of aseptic methods is just as es- 
sential in this work as in any department of surgery, and 
in this connection we must not forget the difficulty of 
rendering clean the vulvar orifice and also the proneness 
of the bladder to become infected. The vagina should be 
scrubbed out with hot water and sterile soap, and the folds 
of the vulva well separated and washed. All instruments 
are boiled or otherwise sterilized. These matters are at- 
tended to by the nurse; but after anaesthesia is complete 
and the patient in position, the urethral orifice is again 
cleaned, the lubricant (preferably boroglyceride) is ster- 
ile, and after all preliminaries are arranged the examiner 
again sterilizes his hands. 

Instruments. — The instruments necessary for examin- 
ing the bladder are few and simple. They consist of a 
vesical evacuator made of a rubber bulb with tube at- 
tached by which urine may be sucked from the bladder as 
it collects; a series of dilators running from five to 
twenty millimeters in diameter, and differing from one 
another by one millimeter in diameter ; three or four 
specula of different sizes, and consisting of short, straight 
tubes fitted with obturators and convenient handles. These 
instruments are all that are necessary for simple inspection 



102 UROPOIETIC DISEASES. 

of the bladder ; in fact, it often occurs that the urethra re- 
quires no dilatation whatever, and therefore the only in- 
struments actually used are the straight tube of proper 
size and the evacuator. 

If the procedure is to include examination of the ureters) 
kidney pelvis, catheterization of the ureter and treatment 
of local lesions in the bladder, the list of instruments must 
include an assortment of specula from 5 to 20 millimeters 
in diameter, probes, applicators, long slender mouse-toothed 
forceps, various sizes and shapes of metallic ureteral cathe- 
ters, to be used in collecting the urine from each kidney 
separately and for dilating ureteral strictures, long slender 
elastic catheters, made of woven silk, used for evacuating 
and washing the kidney pelvis, and also, when coated with 
wax, for detecting stone in the pelvis. 

Illumination. — Efficient illumination of the bladder is 
very essential, and is best attained by use of the 16-candle 
power electric hand lamp with reflector, used in conjunc- 
tion with the ordinary head-mirror, which we are accus- 
tomed to use in making laryngoscopy examinations. 
Where the current used for ordinary electric illumination 
is not to be had, one can get along with the oil "throat 
light " or the portable electric head light. 

SIMPLE CYSTOSCOPY. 

With all the preliminary preparation complete, i. e., 
anaesthesia, posture, an aseptic field, aseptic instruments 
and aseptic hands, the urethra is dilated to its safe limit by 
the successive introduction of urethral dilators properly 
lubricated — the operator takes his vesical speculum in the 
right hand, and, holding the obturator firmly in place, in- 
troduces the instrument through the urethra into the blad- 
der. Now, when the obturator is withdrawn, if the 
anaesthesia is complete and the position correct, air will 
rush in and distend the bladder to its limit. Should there 



SIMPLE CYSTOSCOPY. 103 

be some urine in the bladder, as is usually the case, a little 
will be forced out during any coughing or vomiting fit 
which comes on in the course of the examination. If 
much urine remains, it will be best to completely evacuate 
the bladder by means of the suction apparatus, which 
forms a part of the simple set sold by instrument makers 
for use in making cystoscopic examinations. Adjusting 
now the head mirror so that the eye looks through its 
central opening and the reflected rays of light shine into 
the tube parallel with its long axis, one first sees that por- 
tion of the bladder which lies opposite to the internal 
urethral orifice. If that portion of the bladder is normal, 
it will appear as a smooth white surface, with perhaps a 
tinge of pink and crossed by branching blood vessels 
whose redness stands out in bold contrast. Should the 
patient cough, or otherwise contract the abdominal mus- 
cles, the bladder walls will suddenly contract upon the end 
of the speculum in folds which at the same time become a 
bright red, only to resume the blanched appearance as the 
bladder again expands. If the speculum is withdrawn 
until the urethral wall begins to fold over its end, and is 
then re-inserted just within the bladder, the operator can, 
by gradually changing the angle of the speculum, obtain a 
good view of all parts of the viscus. 

In health, and when the viscus is distended with air, the 
vesical surface presents through the greater part of its ex- 
tent the pale pink appearance described above. 

Here and there muscular bundles make ridges which at- 
tract the attention, and drops of moisture upon the surface 
of the membrane glisten in the strong .light, 

The somewhat brighter red of the base, and especially the 
region of the ureteral orifices, is entirely normal, but should 
it appear upon the fundus it would indicate hyperemia or 
inflammation. 

Hyperemia of the base of the bladder is very common, 



104 UROPOIETIC DISEASES. 

is, in fact, the only apparent lesion in most cases of simple 
" irritability " of the bladder without actual inflammation. 
In these cases, the endoscope, when directed toward the 
base of the bladder, reveals a strikingly bright red color 
and in places the same oedema which we are accustomed 
to meet upon all inflamed mucous membranes. 

The traumatism of catheterization or introduction of the 
endoscope may cause a hyperemia of the base, which is 
limited to small patches of contact. It is quite common 
to see a patch of hyperemia about the orifice of one 
ureter, and in this location it is often, yes, usually, a sug- 
gestion of some affection of the corresponding kidney, 
causing it to secrete urine which is more or less irritating 
in nature. 

In cystitis the endoscopic picture varies with the distri- 
bution and intensity of the inflammation. The inflamed 
areas, wherever located, are deeply injected — large capilla- 
ries are seen distributed over the surface and even ulcera- 
tion is not uncommon. 

In tuberculosis or tubercular ulceration of the bladder, 
wherever located, the ulcer has the usual granular appear- 
ance of tubercular ulceration in other parts of the body ; it 
has sharp irregular edges and is often located near that 
ureteral orifice which discharges urine from a tubercular 
kidney. 

Tumors of the bladder offer a fertile field for the use of 
the endoscope, for no class of cases is more difficult of diag- 
nosis by the older methods and none more easy by this 
simple innovation, which permits direct inspection. (For 
consideration of the different varieties of bladder tumors 
see Chapter V.) 

Vesical calculi and foreign bodies, although they may 
elude the searcher, cannot escape the eye of an experi- 
enced examiner, and are therefore easily detected during 
the cystoscopic examination. 



URETERAL CATHETERIZATION. 105 

Abnormal openings into the bladder, whether they com- 
municate with some other cavity, as, for instance, the 
uterus or vagina, or whether they end in blind diverticula, 
are apparent and their relations with the ureteral orifices 
can be carefully estimated so that any contemplated opera- 
tive procedure can be so planned that it does not inter- 
fere with the normal flow of urine either from the kidney 
to the bladder or from the bladder to the surface. 

URETERAL CATHETERIZATION. 

Bladder lesions, while annoying, do not as a rule kill, 
while on the other hand, kidney and ureteral lesions are 
universally serious, and yet on account of the deep location 
and inaccessibility of the kidneys and ureters we have 
hitherto often found ourselves obliged to allow patients 
to die naturally rather than to risk the performance of 
an operation for the relief of a condition which we were 
unable to accurately investigate before that operation. It 
is in just this field, namely — surgical diseases of the kid- 
neys and ureters — that catheterization and examination of 
the ureters, the next step in his method, finds its greatest 
field of usefulness. 

Opening into the floor of the bladder by two narrow 
slits, located about an inch apart and three-fourths of an 
inch within the internal urethral orifice, are the ureters, 
and with favorable conditions which are quite within our 
control it is not a difficult matter to introduce into them a 
sound or catheter. One can hardly say that this procedure 
is always easy, nevertheless it is much more easy and cer- 
tain than any of the methods by touch or use of the cysto- 
scope, over which so much time and labor have been 
expended, but which have proven so unsatisfactory. 

The difficulties of Kelly's method of ureteral catheteriza- 
tion are more apparent than real. In the ordinary case 
the procedure is simple, the actual difficulties appear in 



106 UROPOIETIC DISEASES. 

those cases where there is some pelvic growth, adhesion or 
other lesion which distorts or fixes the base of the bladder. 
If the base of the bladder does not come easily into view 
the difficulty may usually be overcome by allowing the 
vagina and even the rectum to become distended with air 
by introduction of a tube into either cavity while the 
patient is in the knee chest position. 

The great value of this method will be appreciated when 
we consider that it takes our instruments into actual con- 
tact with disease so deep-seated that it has hitherto been 
entirely beyond our reach even for examination, except 
as the urinary findings allowed us to infer that which we 
could not demonstrate, and except as the conditions were 
revealed at the conclusion of a major operation. 

Having observed the aseptic precautions mentioned in 
the early part of this article, the endoscopic tube intro- 
duced into the bladder is withdrawn till the internal 
urethral orifice begins to fold over its end, and is then 
pushed into the bladder about half an inch. The handle 
is now depressed until the base of the bladder is in view 
and then the instrument is directed to one side of the 
median line about 25 or 30 degrees, when the ureteral 
orifice of that side should be within view. The operator 
is now ready to begin investigation of the ureters, kidney 
pelvis, and kidney itself. For the accomplishment of this 
purpose he relies mainly upon either the metal ureteral 
or flexible ureteral or renal catheters. The metal cathe- 
ters are made about twelve inches long and two and a-half 
millimeters in diameter, with a slightly-curved conical 
point and having eyes upon the sides. Flexible catheters 
are made upon the same plan as the finer quality of ure- 
thral catheters, u e., of woven silk and coated with varnish, 
and they vary in size from 1 ^ to 3 millimeters in diam- 
eter and from twelve to twenty inches in length. These 
instruments are flexible enough to follow the ureteral 



URETERAL CATHETERIZATION. 107 

curves to the kidney pelvis, will stand boiling for two 
minutes in plain water, and are in fact the instrument 
upon which greatest dependence is placed in ureteral work. 

The ureteral orifice having been located, the sterilized 
catheter in its glass tube is handed the operator, whose 
thumb and finger are protected by sterile finger stalls; he 
lubricates the end of the catheter with boroglyceride, and 
with the tube directed over his shoulder slips the catheter 
out, through the endoscope, and directly into the ureter. 
If it is only desired to collect the separated urines the short 
catheter is sufficient, and when it is well introduced the 
endoscope is withdrawn, reinserted through the urethra 
beside the catheter and a similar procedure executed 
upon the opposite ureter. The patient may now be placed 
in a comfortable position and the catheter ends passed into 
separate test glasses, bottles or tubes and the secretion of 
each kidney collected separately and in an uncontaminated 
condition. 

The information to be gained from the simple proced- 
ure of examining the separated urines is ofttimes of the 
highest value. In this way we are informed of the rela- 
tive secreting power of each kidney, we have a positive 
diagnosis as to the existence of both kidneys and the 
patency of their ureters, microscopical, chemical and bac- 
teriological examination leads to the positive diagnosis of 
nearly all kidney lesions and tells us whether they are 
bilateral or unilateral. Tuberculosis of the kidney or 
ureter, stone in the pelvis or in the ureter, purulent in- 
flammation, hydro-nephrosis aud a vast train of local 
kidney and ureteral lesions reveal themselves as soon as 
we are able to pass a tube directly into the ureter. 

Using a long (20-inch) ureteral catheter, we can test the 
size of the whole ureter, and should its calibre be narrowed 
we can determine the nature and extent of the occlusion. 
If our catheter has its end coated with dental wax we can 



108 UROPOIETIC DISEASES. 

pass it into the kidney pelvis in search oi stone, and 
should it touch one, a low power lens well reveal charac- 
teristic indentations and scratches produced by contact 
with the hard surface of the calculus. This information 
adds vastly to one's confidence when one proceeds with an 
operation for removal of a suspected stone. 

In inflammatory affections of the kidney or its pelvis re- 
sulting from infection, bacteriological investigations can 
easily be made, provided we exercise in collecting the 
specimen that care which we are in the habit of using 
when at work in the laboratory. 

LOCAL TREATMENT THROUGH THE ENDOSCOPE. 

Fully as important as the advances in diagnosis, which 
this method of examination has rendered possible, is the 
great change which it is bringing about in methods of local 
treatment. Previous to its introduction, local treatment had 
been limited to the use of vesical irrigation, there had been 
little attempt at anything more exact or far reaching, and 
even in bladder lesions there still exists an element of un- 
certainty as to the value of the various injections which 
we have used for that great class of cases to which we 
apply the generic term "cystitis," regardless of the spe- 
cific form of infection present. 

The fact that the endoscope permits both manipulation 
and sight in a clear field opens up a wide range of possi- 
bilities for both local application and operative work with- 
in the bladder. 

Foreign Bodies — In no class of cases is this advance 
more striking than where foreign bodies have been intro- 
duced through the urethra or where small calculi have 
formed within the bladder. The former cases originate in 
many ways ; surgeons and nurses not infrequently have the 
misfortune to break off catheters, sounds and other instru- 
ments in the bladder ; insane patients, masturbators and 



LOCAL TREATMENT THROUGH THE ENDOSCOPE. 109 

malingerers introduce all sorts ol substances into the 
urethra, and not infrequently lose them within the blad- 
der. These substances can be removed through the endo- 
scope when their size is not too great. For this purpose a 
pair of very fine, long, mouse-toothed forceps are very use- 
ful. They are introduced through the endoscope and 
grasp the body to be removed by its shortest diameter. 
Large and very irregular bodies are best removed through 
a vesico-vaginal or a supra-pubic incision. 

Vesico-vaginal fistulas are repaired from the vaginal side, 
but it has sometimes happened that one or more sutures 
have accidentally involved the ureter producing serious 
results. This can be avoided by first locating the ureteral 
orifice and passing into it a sound or catheter which is left 
until the stitches are all inserted and tied. 

Hyperaemia of the trigone is amenable, as a rule, to the 
class of remedies — medicinal, dietetic and diluent — which 
are recommended for " irritability of the bladder," but 
when the condition does not improve or refuses to com- 
pletely recover it can usually be cured by placing the 
patient in the knee chest position, introducing the endo- 
scope and applying to the bright red area a 3 or 5 per 
cent, solution of Nitrate of silver and repeating the applica- 
tion every three or four days. Protargol, Ichthyol, and 
other similar substances are sometimes of use. 

Chronic cystitis does not, as a rule, affect the whole 
bladdtr wall equally and aside from the means advocated 
elsewhere in this volume we have a valuable aid in topi- 
cal applications, made to the diseased areas only, through 
the endoscope. This is done by means of an applicator 
wound with cotton, and plan followed is much the same 
as that used in treating erosions of the cervix; i. e., we 
apply first a 5 per cent, solution of Nitrate of silver and 
then follow every three or four days with a 3 or even 1 
per cent, solution till the eroded or ulcerated patch heals. 



110 UROPOIETIC DISEASES. 

Tubercular cystitis. — Aside from the general measures 
which are applicable to, and most important in, all tuber- 
cular lesions, there are local measures which are of even 
more importance. When tuberculosis of the bladder is 
associated with pulmonary or general tuberculosis the 
bladder lesions become of insignificant importance. When 
it is associated with kidney tuberculosis it is useless to 
treat the minor lesion and allow the major one to progress, 
but, after the tubercular kidney has been removed, the 
bladder lesion must be regarded as a local lesion in the 
same sense that we would regard a joint or bone tubercu- 
losis as a local lesion when there was absence of signs of a 
general involvement. Under these circumstances it be- 
comes amenable to the same local measures which are 
applicable to a primary tubercular cystitis, which are, first, 
injections as referred to in Chapter III.; second, direct 
local applications to the ulcers, and, third, such surgical 
measures as curettage, cauterization and excision of the 
ulcerated surface. 

Tumors of the Bladder. — While the field of usefulness 
of the straight tube in the diagnosis of bladder tumors is 
very wide, its applicability to treatment is, up to the 
present, confined largely to small pedunculated growths ot 
a benign nature. These may be removed by the snare or 
by the galvano-cautery operated through the largest sized 
endoscopic tube under the same conditions which we use 
in making a cystoscopic examination. 

TREATMENT OF URETERAL AND KIDNEY LESIONS. 

The application of Kelly's method to treatment of 
ureteral and kidney lesions is as yet more or less experi- 
mental, but it has already been found to be of great value 
in accomplishing, by use of bougies of graduated sizes, the 
dilatation of cicatricial stricture of the ureter, and by use 
of the renal catheter we are able to safely and successfully 



TREATMENT OF URETERAL AND KIDNEY LESIONS. Ill 

wash the kidney, pelvis and ureter in infectious lesions ot 
these deep urinary tracts. The technique of lavage of the 
kidney pelvis is very simple. The long ureteral catheter 
having been passed to the kidney pelvis it is connected 
with an ordinary funnel and rubber tube, and by elevating 
the funnel when filled with an antiseptic fluid the kidney 
pelvis is distended, while by lowering the funnel the fluid 
is syphoned off, and by repetition of this process the wash- 
ing can be carried on indefinitely. By this means the 
author has succeeded in producing at will a perfectly 
apparent hydronephrosis, and has seen it subside as the 
funnel was lowered. 



CHAPTER IX. 
CYSTOSCOPY AND URINARY SEGREGATION. 

The possibility of examination of the male bladder 
through the urethra was first practically demonstrated by 
Nitze. Since then cystoscopes with various modifications 
have been invented, which allow not only a view of the 
the interior of the bladder, but of irrigation, the removal 
of small growths and the catheterization of the ureters. 
Cystoscopes in general have a shaft ten to eleven inches 
long, of a calibre of twenty-two to twenty-five millimetres 
in circumference, which contains the optical apparatus. 
The shaft terminates in a short beak about three-fourths 
of an inch in length, which is placed at an angle of 145 
degrees and contains the incandescent lamp and a win- 
dow through which the interior of the bladder can be 
viewed. The beak also facilitates introduction of the 
instrument. A small portion of the surface of the bladder 
opposite to the window is reflected through it upon the 
hypotenuse of a right-angled prism, thence through the 
shaft of the instrument ; when the inverted image is righted 
and focused at the ocular end of the instrument by means 
of two plano-convex lenses, and finally magnified by a lense 
in the eye piece. For general examination the Leiter- 
Thompson cystoscope is a satisfactory instrument, but 
when it is necessary to catheterize the ureters the Caspar 
ureter cystoscope will be necessary. 

Cystoscopes should be cleansed immediately after use 
with soap and warm water, douched with alcohol and 
sterilized in a formaline vapor. Before being introduced 
into the bladder, it should be immersed for a few minutes 



CYSTOSCOPY. 113 

in a cool, 3 per cent, solution of Boric acid. The electrical 
portion should be tested by turning on the current, which 
is best derived from a small storage battery controlled by 
a proper rheostat. 

Cystoscopy can be conducted during a local Cocaine or 
Eucaine, or under general anaesthesia. After the usual 
antiseptic precautions, the patient is placed in the lithot- 
omy position, and, if there is a belief that the bladder con- 
tains blood, pus or other foreign material, it should be 
emptied through a catheter and the bladder douched with 
a warm 3 per cent, solution of Boric acid until free from 
all foreign matter, when four to five ounces of the bo- 
rated solution should be injected and the catheter re- 
moved. If the urine is clear and sterile douching is 
unnecessary, five to seven ounces should be retained in the 
bladder, through which the examination can be made. 
After the bladder is properly distended, either naturally or 
artificially, the cystoscope, lubricated with Lubri-chron- 
din, is introduced on the lines common to the introduc- 
tion of a sound. When the elbowed end enters the blad- 
der, all resistance ceases and the instrument is easily 
rotated. The interior of the bladder is then illuminated 
by turning on the electric current and systematically ex- 
amined. The examination can, if proper care is ob- 
served, be continued for an hour or more. If for any 
reason the contained fluid becomes contaminated by 
blood, pus, etc., the image of the interior of the bladder 
will become obscure and the study will have to be discon- 
tinued. The examination requires much attention to de- 
tail, a knowledge of what may be obtained, and a careful 
consideration of the phenomena presented. 

When the cystoscope is introduced, the beak should be 
turned downward, and the base and trigone first examined, 
after which the posterior surface, vault and finally the 
anterior and vesical opening of the urethra. 
8 



114 UROPOIETIC DISEASES. 

With the ureter catheter cystoscope the examiner is 
often able to enter a catheter into the vesical opening of 
the ureter. The Caspar is a satisfactory instrument and is 
so arranged that after the ureteral openings are found the 
catheter can be made to emerge and by pressure on the 
stilet take any selected angle of direction to facilitate its 
entrance into the vesical opening of the ureter. In the 
male, though a certain percentage of the attempts to ca- 
theterize the ureters are failures, the catheter is often of 
great advantage, in that it enables the operator to irrigate 
some special part and examine it more carefully. 

The surface of the interior of the normal bladder, if it 
contains four or more ounces of a clear fluid, when exam- 
ined through the cystoscope, appears straw yellow in color, 
is slightly trabiculated and presents numerous tortuous 
vessels. When it will not retain this amount of fluid 
cystoscopic examination will be unsatisfactory. Depression 
and half-rotation of the instrument brings into view the 
base of the bladder and trigone, at the outer posterior 
angles of which are located the vesical openings of the 
ureters, from which, at intervals of thirty to sixty seconds, 
a little whirl of urine is ejected. These ejections are not 
synchronous, nor do they occur at any fixed periods. The 
flow of urine may be increased by the ingestion one or two 
glasses of Cartreville water an hour before the proposed 
catheterization. The location of the ureteral openings 
may be marked by slight elevations, slits or furrows. Some- 
times, especially if the bladder is not properly distended, 
their locations cannot be determined. Occasionally they 
are very prominent. The pathological symptoms of the 
diseased bladder, as seen by ocular examination, in the 
male differ so little from that of the female, and have 
been so ably delineated by Dr. Roberts in Chapter VIII. , 
that, in order to avoid repetition, they will be omitted. 
As catheterization of the ureters, which seemingly is of 



URINARY SEGREGATION. 115 

so great importance, is difficult and sometimes impossible, 
even in the attempts of experts, the Harris method of seg- 
regation of the urine has been well received, and as a rule 
it has given excellent satisfaction. In one case of sepa- 
ration by the author one kidney seemed to be secreting a 
urine of deep straw color, of a specific gravity of 1020, 
and the opposite pale and watery urine, of 10 14. With 
this instrument the separated urine can be evacuated under 
cocaine anaesthesia, and often is of great diagnostic value. 
Harris describes his method as follows : 

" The instrument consists of a double catheter, each being 
separate throughout, but both being enclosed in a common 
sheath throughout its shaft or straight portion, thus giving 
it the appearance of a single flattened tube. Each catheter 
is separately movable about its longitudinal axis within 
the sheath. The sheath is 19 cm. in length, and gradu- 
ated in cm. along its upper surface. The proximal portion 
(in reference to the patient) is curved, forming an arc of 
about 60 degrees of a circle, with a radius of 35 mm. 
This curved portion does not pass at once into the straight 
portion, but is set on a slight forward angular displacement 
about 3 or 4 mm. in length. A transverse section of this 
curved portion of a single catheter is approximately a 
semi-circle, so that when the flattened surfaces of the two 
catheters are opposed it is nearly round. In the flattened 
surfaces and the lateral portions of the semi-circular 
surfaces are a number of small perforations. The distal 
extremity of each catheter is round and curved in the same 
plane as the proximal extremity, forming about a quadrant 
of a circle, the same as the curved end of an ordinary male 
sound. The curves of the two extremities being in the 
same plane, the distal end will always indicate accurately 
the exact direction of the proximal end. At about the 
junction of the distal curve with the straight portion is a 
short tube continued in the line of the straight portion and 



116 UROPOIETIC DISEASES. 

opening into it. The distal extremity of each catheter is 
connected by means of a short piece of rubber tubing with 
a separate glass vial. The corks of the vials are doubly 
perforated, and each vial is finally connected by a piece of 
rubber tubing with a single rubber exhaust bulb. There 
is a metal lever about 29 cm. in length, with a handle at 
one end, the opposite extremity being suitably curved and 
flattened laterally. This lever is provided with a single 
perforation near the handle, is flattened on its sides, and 
notched along its lower border. A detachable curved, 
forked metal piece connects the catheter with the lever 
when in use. This connecting-piece is provided with a 
spiral spring arranged to catch in the notches on the under 
surface of the lever. The instrument is used in the fol- 
lowing manner : The patient, male or female, is placed 
comfortably on a table in the ordinary lithotomy position, 
the hips being as high as the shoulders, and the buttocks 
at a sufficient distance from the end of the table to provide 
space for the resting of the vials. The bladder should be 
irrigated with sterilized water before introducing the 
instrument, even when there appears to be no question as 
to the location of the pathological process. 

"After irrigating, from one hundred to one hundred and 
fifty cubic centimetres of water should be allowed to 
remain within the bladder. This facilitates the turning 
of the instrument after its introduction and diminishes the 
liability of exciting hemorrhage from a sensitive or in- 
flamed bladder wall. Before introducing the instrument 
the forked piece should be fixed to the catheter exactly at 
the point indicated. It is necessary to be precise in this 
matter, as the point of fixation is what determines the 
height of the partition or septum in the bladder, and any 
deviation from the point indicated may produce an imper- 
fect partition. 

"The catheter, sterilized by boiling, closed and slightly 



URINARY SEGREGATION. 117 

lubricated with Lubri-chrondin, is then introduced. To pre- 
vent the fluid in the bladder escaping, the tips of the 
instrument must be closed, the straight ones by a short 
piece of rubber tubing, the curved ones by a piece about 
twenty centimetres in length. 

" While the catheter is maintained accurately in the mid- 
line the lever, passed through the fork, is introduced into 
the rectum or vagina, respectively, until the perforation 
near its distal extremity is opposite the perforations in the 
forked piece, when it is fixed by the little pin. In the 
female, the first or second perforation, numbering from 
above, is used, while in the male one of the lower holes is 
used in order to accommodate the varying-sized prostate. 
In a small or close vagina there is, at times, a tendency 
for the inner end of the lever to slip to one side of the 
catheter before it is opened, being drawn forward by a firm 
lavator ani muscle. This is easily guarded against by 
nolding the lever firmly in the midline. 

"The instrument is now opened by rotating the catheters 
slowly and gently until the distal extremities point out- 
ward and backward, where they are fixed by the small 
spiral spring. The large spiral spring is caught in the 
notches on the lower border of the lever so as to produce 
moderate pressure only, thus gently crowding the inner 
end of the lever between the diverging ends of the cathe- 
ters. Upon opening the instrument it almost always as- 
sumes its correct position as regards the base of the blad- 
der ; to insure that it is not too far in, it should be gently 
drawn on until one feels the resistance of the tissues to its 
further withdrawal. When held properly in position, the 
lever should be horizontal, the catheter itself having, at all 
times, an inclination upward and outward. The end of 
each catheter in the bladder now occupies the bottom of a 
little pocket, the pockets being separated by a perfect sep- 
tum or watershed. The ureters open, one on either side 



118 UROPOIETIC DISEASES. 

of the watershed, near the base of the declivity in the im- 
mediate vicinity of the respective ends of the catheter. 
The rubber tubing closing the curving tips is now re- 
moved, and the fluid in the bladder permitted to escape 
after which the catheters are attached to the vials, right 
and left, respectlveiy. 

"If for any reason, it is deemed desirable further to irri- 
gate the bladder, after the introduction of the instrument,, 
it may be done through the straight tips before detaching 
the tubing from the curved tips. If hemorrhage is excited 
by the introduction of the instrument, the bladder should 
be irrigated with hot water until all bleeding ceases and 
the water returns perfectly clear. 

"After emptying the bladder the first fluid that drops into- 
the vials is simply the water that remained in the cathe- 
ters and tubes and must be discarded. As each catheter 
and tube hold about three or four cubic centimetres of 
fluid, we must wait until that much urine has come down 
from each kidney to displace the water, before collecting 
for examination or timeing the flow. The aspirating bulU 
should be used but sparingly and only with the greatest 
gentleness. Vigorous manipulation of it is never permis- 
sible, as it is not only painful to the patient, but may ex- 
cite hemorrhage from the bladder. Its use, however, can- 
not with safety be dispensed with entirely, as the abdominal 
walls may be so lax as to produce, when lying down, 
almost a negative tension in the bladder, so that the. urine 
may accumulate in the bladder in sufficient quantity to 
overflow the septum unless kept aspirated by the bulb. 
Usually, when the flow is once started, the dependent posi- 
tion of the vials and tubes produces sufficient siphonage to 
insure the immediate escape of the urine as soon as it 
leaves the ureters, without the further use of the bulb. 

"The flow of urine usually begins as soon as the instru- 
ment is adjusted, but this is not always the case. It fre- 



URINARY SEGREGATION. 119 

quently happens that four or five or even more minutes 
elapse before the urine begins to drop into the vials. 
There appears to be a slight or temporary suppression. 
Sometimes there is a wait of fifteen to twenty minutes for 
the flow to begin; but, when once started, it procedes 
with regularity. The flow is never continuous, but always 
intermittent; four to six drops every few seconds, first 
from one side then from the other." 



CHAPTER X. 

VESICAL THERAPEUTICS. 

Acidum benzoicum. — Cystitis. Frequent urination. Ir- 
ritable bladder. Nocturnal enuresis of children. Urine 
offensive, brown, containing pus and mucus. Urine 
changeable in odor, usually very disagreeable and offen- 
sive, cloudy, alkaline in reaction, containing phosphates 
and carbonates in large quantities. Urine sometimes 
thick and bloody. Weariness in the inguinal regions. 
The patient pale and anaemic. Frequent desire to urinate 
with tenesmus. Specific gravity of urine high from in- 
crease of uric acid. Urine offensive, smelling like horse 
urine. 

Acidum nitricum. — Cystitis. Burning pain in the 
bladder. Urging after micturition with shuddering along 
the spine. Burning pain in the urethra and cutting pain 
in the abdomen on urinating. Incontinence in old, 
broken-down men. Enuresis. Urine is offensive and 
contains pus and mucus. Urine ammoniacal ; smells like 
horse urine, with white sediment. Bloody urine. Urine 
is cold when passed. 

Acidum phosphoricum. — Cramps in the region of the 
kidney. Abnormal alkaline urine. The urine looks like 
milk and decomposes quickly. 

Aconitum napellus. — Cystitis and retention of urine. 
Inflammation and congestion of the mucus membrane of 
the entire urinary tract. Painful micturition with great 
anxiety. Urine scanty, red and hot. Burning in the 
urethra after micturition. Retention of urine from sudden 
chilling of the surface. Tenesmus with burning at the 



VESICAL THERAPEUTICS. 121 

neck of the bladder. Enuresis with thirst. Inflammation 
of the bladder and kidneys. Tenderness over the hypo- 
gastric region. Violent burning in the bladder with 
frequent straining ; urine mixed with blood. Restlessness. 
Skin hot and dry. Hard, quick, full pulse. 

Aloe socotrina. — Incontinence of urine of the aged, 
with each act feels as if he must have a small stool. Bear- 
ing-down sensation with enlarged prostate. Sensation of 
a plug between the sacrum and the coccyx. 

Alumina. — High-colored urine, which can only be 
passed when straining at stool. 

Apis mellifica. — Urine dark-red and scanty. Inflamma- 
tion of the bladder. Vesical tenesmus. Incontinence of 
the urine with great irritation of the parts. Burning and 
soreness when urinating. 

Argentum nitricum. — Urine high-colored, scanty and 
strong smelling. Inability to pass urine in a projecting 
stream. Incontinence of urine, especially in the aged, 
late. 

Arnica montana. — Injuries of the bladder or ureters. 
Bloody urine from mechanical violence. Tenesmus. Fre- 
quent desire to urinate with involuntary urination. Re- 
tention. Involuntary micturition during the day or when 
moving. Urine brown, high-colored, bloody, containing 
phosphates. Urine passed drop by drop, has to wait some 
time before the act can be commenced. Pressing pain in 
kidney and ureters after the passage of a calculus with 
bloody urine. 

Arsenicum album. — Atony of the bladder with reten- 
tion. Difficult micturition. Burning pain, especially on 
beginning to urinate. Face pale, extremities cold, rest- 
lessness, fever. Bladder greatly over-distended. Involun- 
tary micturition from paralysis of the bladder (overflow). 
Enuresis at night during sleep. Tenesmus. Strangury. 
Urine mixed with pus, turbid, greenish, foul-smelling> 



122 UROPOIETIC DISEASES. 

slimy, dark-brown sediment. Urinary fever. Fetid 
diarrhoea. 

Aurum metallicum. — Retention of the urine. Tenes- 
mus and frequent desire to urinate. Urine turbid, like 
buttermilk, with a thick sediment of mucus. 

Belladonna. — Acute cystitis. Irritable bladder from 
hypersesthesia. The region of the bladder is very sensitive 
to touch. Incontinence of urine. Enuresis at night with 
sudden starting up from sleep as if frightened. Spasm of 
the urethra. Retention of urine. Urine passed with diffi- 
culty, drop by drop, with tenesmus and constant desire. 
Urine sometimes bloody. Continual dribbling of urine. 
Urine scanty, red, turbid, dark, sometimes as yellow as 
gold. Sharp stitching pain in the perineum, which comes 
suddenly and disappears as suddenly. 

Berberis vulgaris. — Cystitis. Vesical irritability. Burn- 
ing, cutting and sticking pain in the urethra. Frequent 
micturition with burning before and during the act, es- 
pecially in the female. Violent stitching, tearing, burning 
pain in the region of the kidney, extending forward along 
the course of the ureters into the bladder, to the posterior 
part of the pelvis and thighs ; worse when stooping, lying 
or sitting, relieved by standing. Stitches from the kid- 
ney to the bladder with frequent desire to urinate. Draw- 
ing, tensive, tearing pains in the lumbar region. Violent 
stitches in the bladder with frequent urination. Cutting, 
constrictive pain in bladder, whether full or empty. De- 
sire to urinate with burning in urethra. Burning in the 
urethra after urination! Motion aggravates the urinary 
troubles ; pain in the loins and hips generally accompany- 
ing the symptoms. Urine yellow, red with reddish and 
bran-like sediments. Blood-red urine. Greenish urine, 
pale yellow, with slight, transparent, gelatinous sediment 
which does not deposit ; or a turbid, flocculent, clay-col- 
ored, copious mucus sediment, mixed with white or 



VESICAL THERAPEUTICS. 123 

whitish-gray, and later a reddish, mealy sediment. Pain 
in the testicles. 

Calcarea carbonia. — Involuntary discharge of urine 
when walking. Frequent micturition at night. Noc- 
turnal enuresis, urine clear and sour-smelling. Trickling 
of urine after urination. Offensive, dark urine, containing 
thick mucus and depositing a white sediment like flour. 

Camphor. — Tenesmus of the neck of the bladder. 
Strangury. Retention of urine. Micturition frequent, 
difficult and painful, with dribbling of urine or with a thin 
stream as if the urethra were contracted. Frequent in- 
effectual urging to urinate. When urinating pressure in 
the region of the bladder and burning in the urethra. 
Urine scanty, red and thick or yellowish-green, turbid and 
offensive. Retention of urine. 

Cannabis Indica. — Inflammation of the bladder, with 
burning, scalding and stinging before, during and after 
urination. After urination much straining and strangury. 
Dribbling of urine after micturition. Copious discharge 
of clear white or thick red urine with burning. 

Cantharis. — Acute cystitis. Retention of urine. 
Strangury. Gravel, especially in children. Constant and 
ineffectual urging to urinate. Cystitis, generally of gonor- 
rhceal origin. Spasmodic pain in the bladder, with urgent 
desire to urinate. Intense burning in the bladder. Mic- 
turition painful, drop by drop, with a feeling as though, 
melted lead were passing down the urethra with violent 
straining, which increases the pain. Urine at first clear, 
but afterwards tubid, scanty or of blood only. Thirst, but 
drinking always increases the pains in the bladder. Burn- 
ing, stinging and tearing in the region of the kidneys. 
Violent pressing pain in lumbar region, extending to the 
bladder. The cystitis calling for Cantharis is of a high 
inflammatory grade with hematuria ; it may be accom- 
panied by a chill, fever, etc. The specific gravity of the 



124 UROPOIETIC DISEASES. 

urine is always high and it is always acid, containing large 
quantities of urates. In the gravel of children the pains 
extend down the penis, with a constant inclination to pull 
at the organ. 

Cargo vegetabilis. — Chronic cystitis of the aged. Press- 
ing pain in the bladder. Urine has a strong odor, dark- 
colored, as if mixed with blood, and deposits a sediment. 

Causticum. — Incontinence of urine, from want of power 
in the vesical sphincter. Paralysis of the bladder after 
labor, with retention of urine. Involuntary discharge of 
urine when coughing, during the first sleep at night, and 
from the least over-exertion or excitement. Pulsating 
pain in the perineum. Pain in the bladder after a few 
drops of urine have been passed. Urging to urinate, but 
must wait a long time before he commences to act, which 
may afterwards be involuntary. Urine light-colored, with 
flocculent sediment. Iyithiates. 

Chimaphila umbellata. — Chronic cystitis. Vesical 
tenesmus, the urine containing large quantities of ropy 
mucus. Scanty urine. Inability to pass the urine with- 
out standing with the feet widely separated. Desire to 
urinate, with great burning and smarting, which is not 
relieved by micturition. This drug is very frequently 
indicated in both acute and chronic inflammation of the 
bladder ; the urine is high colored, with a bloody, greenish 
or reddish sediment, but has particularly large quantities 
of thick, ropy, slimy, fetid mucus, with much mucu- 
purulent deposit. 

Chininum sulphatum. — Urine is scanty, acid, turbid, of 
strong odor, and flows slowly, with a sediment of yellowish- 
red crystals, or clear, containing four-sided prisms, the 
pointed ends being enveloped in mucus. Urine turbid, 
alkaline, chocolate-colored, with ' phosphates increased. 
Cramping and neuralgic pains in the region of the kidneys. 
Sediments yellowish-white, mealy, of strong odor, brick- 



VESICAL THERAPEUTICS. 125 

dust, slimy flakes, with large numbers of transparent, 
colorless and orange-colored crystals, star-like, rhomboidal 
and flat crystals, mostly phosphates. 

Coccus cacti. — Chronic cystitis. Cutting and heaviness 
in the bladder and constant urging to urinate, relieved by 
micturition. Frequent ineffectual attempts to urinate at 
night ; has to wait a long time before he can succeed. 
Retention of urine until there is intense pain, when a 
small amount is passed slowly, with much suffering. Pain 
and soreness in the region of the bladder. Hsematuria. 
Urine contains large deposits of urates and uric acid, and 
is thick, hot, acrid and burning. 

Colchicum autumnale. — Frequent desire to urinate ; 
urine is dark and scanty, depositing a whitish sediment. 

Colocynthis. — Frequent discharge of a small quantity 
of urine with tenesmus, followed by burning in the 
urethra. Urine viscid, like thin glue, which thickens on 
standing and is fetid. Urine turbid, with copious deposit 
of hard, reddish crystals. Uric acid. Chlorides dimin- 
ished. 

Conium maculatum. — Much difficulty in voiding the 
urine ; it flows and stops, then starts and flows again at 
each emission. Frequent urination during the night. 
Pressure on the bladder, the urine cannot be retained. 
Pressing pain and stitches at the neck of the bladder, worse 
irom motion, better on sitting. Urine thick, white and 
turbid. 

Copaiva. — Acute cystitis, especially in the course of a 
gonorrhoea. Constant desire to urinate. Intense inflam- 
mation of the bladder, especially at the neck. Burning 
and a sensation of dryness in the region of the prostate 
gland and neck of bladder. Urine passed in drops, with 
great pain and straining. Urine foaming, greenish, turbid, 
bloody, smelling like violets. Irritability of the neck of 
bladder and urethra in old women. 



126 UROPOIETIC DISEASES. 

Cubeba. — Cystitis. Tenesmus, with smarting on the 
passage of the urine, which may be foamy and contain 
ropy mucus. 

Digitalis purpurea. — Throbbing pain in the region ot 
the neck of the bladder during micturition. Increased 
desire to urinate after a few drops have been passed, caus- 
ing great distress and associated tenesmus of the rec- 
tum. Ineffectual efforts to urinate, with the discharge 
of a few drops of urine and a continued fullness after 
urinating. Urine is dark brown, hot and burning when 
passed. Excessive quantity of urine. The urine is 
retained more easily in the recumbent position. 

Dulcamara. — Cystitis, especially when caused by ex- 
posure to cold or damp, and where the disease tends to 
become chronic, or in chronic cases which are aggravated 
by a change to damp, cold weather. Urine turbid, white, 
or fetid. Painful, frequent urination. Retention. Invol- 
untary discharge of urine, from atony of the bladder. 
Thickening of the muscular coats in chronic cystitis. 

Equisetum hyemale. — Nocturnal enuresis. Inconti- 
nence of urine in the aged, especially in women. Pain in 
the bladder not relieved by urinating. Pain as from dis- 
tension. Constant desire to urinate, which micturition 
does not relieve. Tenderness over the bladder. Frequent 
desire to urinate, but only a small quantity is passed. 
Weakness of the bladder, drippling of urine, and pain as 
from over-distension. Urine scanty, high-colored, bloody, 
albuminous, showing great excess of mucus on standing. 

Erigeron canadensis. — Catarrh of the bladder, with 
much pain. Children cry when urinating, from the pain. 
Urine profuse, bloody, of strong odor. Stone in the blad- 
der. 

Eucalyptus. — Chronic catarrh of the bladder and genito- 
urinary tract. The urine smells like violets. 

Gelsemium semporonus. — Frequent desire to evacuate 



VESICAL THERAPEUTICS. • 127 

the bladder with discharge of copious, limpid urine re- 
lieving- the dullness and heaviness of the head. Constant 
dribbling of urine from muscular weakness. Bladder dis- 
tended with urine ; retention and overflow. Enuresis at 
night. Dysuria and spasmodic retention of urine from 
cold, etc. Feeling on urinating as if some of the urine 
remained behind, with a small intermittent stream. Post- 
diphtheritic paralysis of the sphincter. 

Graphites. — Frequent micturition, especially at night. 
Urine sour-smelling, depositing a thick sediment with pain 
in sacrum on urinating. 

Hepar sulphuris calcarea. — Micturition slow, has to 
wait some time for the urine to flow, when it does so 
slowly ; it may drop straight down from the end of the 
penis. The patient is never able to finish, he always feels 
as if some was left in the bladder. Urine is dark-red, hot, 
and becomes thick, turbid and deposits a white sediment 
on standing. 

Hydrastis canadensis. — Catarrhal inflammation of the 
bladder with thick, ropy mucus in the urine. 

Hyoscyamus niger. — Retention of urine, bladder dis- 
tended. Involuntary discharge of urine. Frequent mictu- 
rition. Prolapsus of the bladder. Difficult micturition, 
must strain from pressure. Urine turbid, depositing mu- 
cus or a purulent sediment. Difficult micturition, inflam- 
mation not far advanced ; in cases where the trouble is 
more spasmodic than inflammatory. 

Ignatia amare. — Sensation of scraping and smarting 
in the neck of the bladder. Sudden, irresistible desire to 
urinate, especially when walking. Frequent discharge of 
watery urine. Pressure to urinate from drinking coffee. 
Urine lemon-colored, with white sediment. 

Kreosotum. — Urine has an offensive smell and is of 
deep red color, with reddish sediment. 

Lachesis. — Urging and inability to urinate, with press- 



128 UROPOIETIC DISEASES. 

ure and dull pain in the bladder. Sensation of a ball roll- 
ing in the bladder on turning in bed. Urine profuse, 
foaming and offensive, varying from a coffee color to black 
and discharge of a bad-looking mucus with the urine. 

Lycopodium clavatum. — Dull pressing pains and 
stitches in the bladder. Stitches in the neck of the blad- 
der and anus at the same time. Pressing pain in perineum 
during and after micturition. Urging to urinate, must 
wait some time before he can pass it. Frequent desire to 
urinate with scanty flow. Terrific pain in the back pre- 
vious to each urination, relieved as soon as the flow begins. 
Smarting and burning when urinating. Drawing, cutting 
pain through to the abdomen. Pain in the kidney and 
bladder with frequent urination. Calculus with bloody 
urine. Urine profuse, dark, bloody, with much red, sandy 
sediment. Greasy pedicle in urine. Red sand on child's 
diaper. Before micturition the child screams with pain. 
Urine scanty and red. Copious, red, sandy deposits. 
Urine turbid, milky, with a thick purulent sediment and 
offensive odor. Aching pain in rectum. 

Mercurius. — Cystitis. Feeling of great pressure and 
heat in the perineum. Heaviness and aching in the gland, 
which is swollen and hard. The urinary stream is exceed- 
ingly small, passed drop by drop, with a whitish sediment. 
Soreness to touch in the region of the bladder. Urgent 
desire to urinate, the urine may contain mucus, pus or 
blood. Gonorrhceal cystitis. Urine is turbid and fetid. 

Mullein oil. — Dr. A. M. Cushman, who proved this drug 
says that it produces constant dribbling of urine day and 
night. The remedy acts very satisfactorily in nocturnal 
enuresis, also in diurnal incontinence ; it also corrects the 
over-acidity. 

Nux vomica. — Irritable and gouty bladder. Spasmodic 
retention of urine. Frequent desire to urinate, but little 
is passed at a time and is accompanied by much burning. 



VESICAL THERAPEUTICS. 129 

Painful and ineffectual efforts to urinate. Burning and 
tearing pain in the neck of the bladder on urinating. 
Violent straining when urinating. Paralysis of the blad- 
der ; the urine flows drop by drop as it is formed. Urine 
pale, containing thick, white mucus or purulent matter. 
Dark urine, depositing a red brick-dust sediment. Bloody 
urine. Strangury. 

Opium. — Atony of the bladder. Retention of the urine, 
and the sensibility is so blunted that the urine passes un- 
noticed. The urine is only passed after much effort. 
Lemon-colored urine with more or less sediment. 

Pareira brava. — Cystitis. Violent urging and strain- 
ing to urinate, pain extends into the glans penis and down 
the thighs, even into the feet. Strangury. The pain is 
so agonizing that the patient can only urinate when on his 
knees with the head pressed against the floor. Paroxysms 
occur after midnight. Great burning on urinating. The 
urine is ammoniacal, containing thick, white viscid mucus. 

Petroleum. — Involuntary discharge of reddish-brown, 
fetid urine. 

Phosphorus. — White flocculent sediment in the urine. 
Acrid, offensive urine. Bloody urine. Thick, turbid, 
scanty urine. Bloody urine with pain in region of the 
kidneys. 

Plumbum metallicum. — Paralysis of the bladder from 
spinal disease. Atony of the bladder. Tenesmus and 
difficult urination. Urine dark-colored and passed drop by 
drop. Urine scanty. The patient is unable to urinate be- 
cause he lacks sensation to make the will act on the 
bladder. 

Pulsatilla pratensis. — Cystitis. Pain at the neck of 
the bladder, with an intermitting stream of urine and spas- 
modic, contracting pains at the end of urination. Frequent 
desire to urinate. Spasmodic pain at the neck of the 
bladder extending to the pelvis and thighs. Frequent and 
9 



130 UROPOIETIC DISEASES. 

almost ineffectual urging to urinate. Involuntary urination 
at night in bed. Constant pressure in the bladder with 
frequent desire to urinate. The urine is discharged while 
walking or standing. Urine bloody ; reddish ; mucus ; 
jelly-like, slimy and sticks to the chamber. Brick-dust 
sediment. 

Populus tremelus. — Catarrh of the bladder. Severe 
tenesmus of old people on voiding urine which contains 
large quantities of mucus and pus. Pressure and aching 
in the pelvis. 

Prunus spinosa. — Irritability of neck of bladder. Te- 
nesmus. Must urinate every fifteen minutes. Burning 
pain in sphincter. Burning pain and ineffectual urging 
to urinate. Relief on passing the urine, but there remains a 
sticking pain in the glans penis which causes a spasm of 
the urethra and rectum. Strangury. Urine scanty and 
brown. 

Rhus aromatica. — Involuntary micturition day or 
night; especially in children. Some consider it almost 
a specific against wetting the bed. Burning pain on 
urinating. Catarrh of the bladder. 

Rhus toxicodendron. — Incontinence of urine during 
est. Snow-white sediment in the urine. Vesical tenes- 
mus. Discharge of blood-red urine in drops. Retention 
of urine from getting wet. Urine is passed slowly. Dark 
urine soon becoming turbid. 

Ruta graveolens. — Pressure at the neck of the bladder 
after urinating as though it was still full. Involuntary 
micturition at night in bed, and even during the day on 
motion. Frequent micturition at night. 

Sandal- wood. — Cystitis. Deep pain and uneasiness in 
the perineum. Urinary stream small and passed with 
difficulty. Sensation of a ball at the neck of the bladder, 
increased on standing, relieved by exercise. Desire to 
change position. 



VESICAL THERAPEUTICS. 131 

Sabina. — Retention of urine. Diminished flow with 
tenesmus. Frequent urination with profuse flow of urine. 
Bloody urine. 

Sabal serrulata. — Cystitis. Incontinence of urine. 
Thin steam, flow intermittent, has to wait for the first drop. 
Tenesmus, frequent urging. Micturition unsatisfactory, 
passes but a few drops at a time. Intense straining when 
urinating. Crying and screaming when urinating. In- 
continence of urine during the day from lifting, straining 
or laughing. 

Sarsaparilla. — Cystitis. Abdomen distended. Severe 
tenemus ; passes gravel and small calculi. Painful constric- 
tion of the bladder. Micturition frequent and ineffectual, 
ending by passing some blood ; chills run from the bladder 
to the back. Gravel passes after urinating ; has to get up 
in the night frequently to urinate. Retention of urine. 
Urine copious ; clear ; white ; scanty and slimy ; clay- 
colored and scanty. Sand in the urine or on the diaper. 
Child screams before and during micturition. The urine 
contains pus, blood and mucus. Fiery red, turbid urine 
with long flakes. Urine excoriating. 

Selenium. — The patient is unable to urinate ; has to 
wait for some time, followed by involuntary dribbling. 
Dark-red, scanty urine, with more or less sandy sediment. 

Sepia. — Chronic cystitis. The lower part of the abdo- 
men feels distended, with tension and soreness. Frequent 
painful and ineffectual urging to urinate, until long effort 
and waiting have about tired out the sufferer. Desire to 
urinate, with bearing down in the pelvis. Burning and 
cutting when urinating. Nocturnal enuresis during the 
first sleep or on going to sleep. Urine dark, turbid, and 
mixed with pus ; thick, slimy, turbid and offensive, depos- 
iting a pasty sediment. Chill and heat in the head during 
and after micturition. Pulsation in the small of the 
back. Sprained pain over the hips. The discharge 01 



132 UROPOIETIC DISEASES. 

mucus in the urine does not take place every time the 
urine is passed, but occurs periodically. Fetid urine, with 
reddish, clay-colored sediment adhering to the chamber. 
The urine is so offensive that it must be removed at once. 

Stigmata maidis. — Acute and chronic cystitis. Urine 
containing blood, mucus and pus. Vesical tenesmus and 
irritation, with constant desire to micturate. Great tenes- 
mus over the entire abdomen, especially along the course 
of the ureters. Retention of urine. 

Staphisagria. — Frequent desire to urinate ; the urine is 
passed in a small stream or only in drops of dark urine 
with much urging. Burning at neck of the bladder with 
urging, as if the bladder was not empty. Profuse, pale, 
watery urine, with much urging. 

Sulphur. — Cystitis. Constant urging to urinate day 
and night, in a thin stream or drop by drop ; the urine is 
high-colored and turbid, of penetrating odor, with thick 
deposit, which sticks to the chamber. Retention of urine. 
Urinates frequently, with a feeling of obstruction at the 
neck of the bladder and a sense of pressure and distension. 
Bruised sensation in small of back after micturition. The 
pains continue in the urethra until the urging to urinate 
returns. Increased secretion of urine. Frequent urination 
at night. The desire comes suddenly, is imperative, and 
if not gratified at once micturition becomes involuntary. 
The urine is clear, high-colored, turbid and excoriating. 

Terebinthina. — Strangury. Tenesmus of the bladder. 
Cystitis. Congestion of the urinary organs. Scanty, 
bright-colored, or bloody urine. Pressure in the bladder, 
extending to the kidneys, disappearing on walking. 
Burning in the bladder, with violent dragging, cutting 
and burning pain. Urine scanty, bloody ; black, like 
coffee, turbid, with thick, dark sediment. 

Thuja occidentalis. — Cystitis. Stitches from the rectum 
to the bladder and from the bladder to the urethra. In- 



VESICAL THERAPEUTICS. 133 

continence of urine, from paralysis of the sphincter. 
Frequent urging to urinate; the stream is often inter- 
rupted. Frequent micturition during the night. Dis- 
charge of a few drops of urine after urinating, with burn- 
ing, stitching and itching in the urethra. The urine is 
clear when passed, but becomes cloudy on standing. Urine 
red, with brick-dust sediment. 

Uva ursi. — Frequent desire to urinate. A small quan- 
tity of urine is passed with burning and followed by cut- 
ting at the neck of the bladder and great straining. The 
urine is slimy, yellow, purulent and bloody. Painfulness 
and soreness in the region of the kidney. Uneasy feeling 
in the left thigh and frequent desire to urinate ; the stream 
is small, with considerable effort to empty the bladder, 
which is done slowly. Pain and soreness in the left groin. 
Heavy pain in the lumbar region and uneasiness in the 
bladder. The urine is red, scanty, high-colored and acid. 

Vesicaria communis. — Urine high-colored, cloudy, 
containing mucus, pus, blood, and shreds of lymph. 
The acute cystitis calling for this drug is often attended 
with a rise in temperature and extreme irritability of the 
bladder, feeling of weight and pain in the hypogastric 
region, which is increased by motion or pressure. Pain may 
extend to the iliac and sacro-lumbar regions. Urine is 
voided drop by drop, accompanied by a straining and scald- 
ing sensation. In chronic cystitis, urine loaded with a 
viscid sediment, thick and glairy, containing large quanti- 
ties of pus corpuscles and triple phosphates, with dull 
pains in the bladder region and frequent desire to micturate. 



CHAPTER XL 
ANOMALIES OF THE KIDNEYS AND URETERS. 

From a surgical, if not from a medical standpoint, the 
possibilities of malformation, the absence of either, or a 
supernumerary kidney, should always be considered. Con- 
genital absence of one kidney is not the rare condition it 
was once thought to be. The left is the most frequently 
missing ; within the past two years three cases of congen- 
ital absence of the right kidney have been reported to the 
New York Pathological Society. This anomaly occurs 
about once in every four thousand births. 

Where but one kidney is present, it will be found en- 
larged, and usually fully competent to functionate for the 
whole body, and will cause no clinical symptoms. When 
one kidney has been removed, compensatory hypertrophy, 
with increase in function, occurs in the remaining organ. 

Whenever nephrectomy is proposed, the presence of 
both kidneys should be positively ascertained, not only by 
palpation and percussion over the kidney region, but by 
cystoscopic examination and catheterization of the ureters. 

Sometimes the kidneys are united at their lower ends,, 
and a horseshoe contour produced, the concavity looking 
upward ; this formation is due to dislocation and amalga- 
mation of the embryonic points of origin. The ureters 
usually pass to the bladder in front of this connecting 
band ; they may emerge behind it or even cross each other. 
Less frequently the kidneys are joined at their upper ends. 
Cases have been reported where a horseshoe kidney was 
found in front of the great vessels. Furthur dislocation 



ANOMALIES OF THE KIDNEYS. 135 

and amalgamation may form a seeming double or tabu- 
lated kidney ; occasionally while one kidney is normal in 
all respects, its fellow may be located over the sacro-iliac 
synchondrosis, or between the bifurcation of the aorta. 
Dr. G. A. Tuttle presented a kidney at the N. Y. Patho- 
logical Society, April 8, 1896, which he had removed 
from the hollow of the sacrum, its renal artery being given 
off close to the origin of the sacro-median. Entire absence 
of renal tissue has not infrequently been observed in 
autopsies of infants. 

There is usually one ureter which connects its kidney 
with the corresponding side of the bladder, though not 
infrequently two or more ureters leave the pelvis of the 
kidney, joining about one or two inches from their 
origin in a common ureter which terminates in the bladder. 

In the female a ureter has been known to open at or 
near the meatus urinarius giving rise to continuous inconti- 
nence. In these cases the ureter, in place of opening into 
the bladder, was continued between the septum of the 
bladder and vagina and opened externally, one each was 
reported by Dr. F. H. Davenport, Trans.-Am. -Gynaecologi- 
cal Society, 1890, and Dr. Baker, N. Y. Med. Journal, 
1878. Mr. Davis Colby, in the Path. Society, London, 
Vol. XXX., reports a case where the ureter on the left side 
was continued through the bladder and urethra and opened 
at the meatus urinarius. It is not uncommon to find the 
ureters greatly dilated, sometimes even to the calibre of 
the small intestines, due to obstruction lower down the uri- 
nary tract. Sometimes, where there is marked contrac- 
tion or obliteration of the bladder, the dilated ureter acts 
as a bladder or reservoir for the urine. There are cases in 
which the ureteral dilatation in children must be consid- 
ered congenital, as no obstruction is discovered at the 
autopsy. 



136 UROPOIETIC DISEASEvS. 

. It is not uncommon for the renal artery to enter the kid- 
ney at the pelvis by a number of branches, at the side, or 
on the convexity of the organ. 

NEPHROPTOSIS. 

Floating and movable kidneys differ in the fact that a 
floating kidney is congenital, has a complete meso-nephron 
and is attached to the posterior wall of the abdominal 
cavity by an extensive band of connective tissue, which 
allows of great latitude of motion. A movable kindey is 
an acquired condition, due to its traumatic relaxation from 
the abdominal parietes, to absorption of the peri-renal 
adipose tissue which holds the kidney to the posterior 
abdominal wall, or anything interfering with the balance 
between the force exerted upon the kidney from above 
downward and backward and that from below upward 
and backward, which presses the kidney back against the 
posterior abdominal wall by a wedge-like process. A 
movable kidney may become so mobile as to allow of 
almost, if not quite, as much latitude of position as the 
floating variety. As both types present similar symptoms 
and may require the same treatment they will be described 
together. 

Etiology. — A floating kidney is always congenital, 
while a movable one is acquired. Increased motion of the 
kidney is often the result of various forms of traumatism. 
The researches of His and Cunningham have given a 
clear description of the normal anchorage of the kidney, 
and the causes which engender an excessive mobility: 
" The kidneys are pressed back into their place by two 
forces — one from above pressing the kidney downward 
and backward, and one from below pressing it upward 
and backward — the wedge-like backward pressure keeping 
the kidney in its normal position. The effect of this 
pressure can be seen on kidneys that have not undergone 



NEPHROPTOSIS. 137 

post-mortem or ante-mortem change from position of the 
body or disease — the anterior surface of the kidney appears 
prominent transversely at its centre, and falls off on an 
inclined plane towards its superior and inferior extrem- 
ities. This wedge-like pressure is produced on the right 
side from above by the liver, and from below by the colon ; 
on the left side it is produced from above by the supra- 
renal capsule, stomach and spleen, and from below by the 
intestines, which press upward and backward. On the 
right side, as the liver, kidney and colon move together 
during respiration and bodily position, the relative forces 
are usually about the same, but on the left side there is a 
greater degree of mobility, due to the varying condition of 
the intestines — the upward and backward pressure being 
less when the intestines are empty, and greater when they 
are distended with gas — the general pressure upward and 
backward upon both kidneys is generally maintained, but 
the lower force is the weaker, consequently anything 
which diminishes the upward and backward pressure will 
be a factor in the production of, or will cause, a movable 
kidney." 

Childbirth is undoubtedly the most frequent cause 
of nephroptosis, some authorities claiming that one 
in every six or seven women who have borne children 
suffer from this condition. The majority of recorded 
cases occur between the twenty-fifth and thirty-fifth year, 
yet Dr. W. W. Stewart, in the Medical Record, Feb. 9, 
1895, reports a case occurring in an infant of eight 
months. Edebohls, in a report of twenty-two consecutive 
cases, found fifteen in unmarried and seven in married 
women. Other authorities believe that corsets are the 
most frequent source of this condition, but this has been 
largely disproved by the fact that German women of the 
lower classes, who never wear corsets, are especially prone 
to this disorder. Falls and injuries and the lifting of 



138 TJROPOIETIC DISEASES. 

heavy weights sometimes produce a nephroptosis. Rapid 
absorption of the connective tissue surrounding the kidney 
in acute or chronic wasting diseases, or the acute over-dis- 
tension of the kidney, and rapid reduction of its volume, 
as in acute hydro-nephrosis, etc., are frequently the deter- 
mining causes. The faulty position of the body in sitting 
or standing and improper modes of dressing are believed 
to be predisposing factors. It occurs, according to the 
statistics, almost seven times as often in the female as 
in the male, but as physical examination becomes more 
complete, the ratio will probably be found to be less. 
The right kidney is usually the one affected, due, accord- 
ing to some authorities, to the downward pressure of the 
liver. In a few reported cases both kidneys have been 
movable. 

Clinical History. — The movable is usually much more 
painful than the floating kidney, and is said to be fifty 
times as frequent in occurrence. In many cases, no un- 
pleasant symptoms are perceived, and the condition passes 
unnoticed only to be revealed at the autopsy, or acci- 
dentally discovered when the patient through fear of a 
tumor seeks medical advice. These probably include the 
larger class. 

In the second class, there is a sensation of something 
wrong or loose within the abdominal cavity, accompanied 
by flatulence, nausea and possibly vomiting, palpitation of 
the heart, or obscure gastro-intestinal and nervous phe- 
nomena, with varied mental symptoms, melancholia, etc. 
Transitory or continuous pain, at times excruciating, 
is often present in the region of the involved kidney, 
extending into the labia in the female, the testis in the 
male, and down the groin and along the course of the 
anterior crural nerve. 

In the third class, when the pedicle is long and the kid- 
ney excessively movable, the ureter and its associated ves- 



NEPHROPTOSIS. 139 

sels may become temporarily twisted or strangulated, and 
cause agonizing pain, vomiting, distension of the abdomen, 
collapse, etc., a condition known as Deith's or the renal 
crisis. This is due to torsion or pressure on the vessels and 
nerves of the cord, with over-distension of the ureter and 
pelvis of the kidney by retained urine. The torsion, how- 
ever, is soon righted by over-distention of the ureter, and 
the symptoms disappear, though in many cases a hydro- or 
pyo-nephrosis is produced. As a rule, there are no urinary 
symptoms of special importance, except those of a resulting 
acute, hydro-nephrosis — i. e., the quantity of urine being 
markedly diminished while the ureter is constricted by 
the torsion, followed later by the passage of a large quan- 
tity of light color. Before and during a renal crisis there 
is frequent and sometimes painful urination. 

The nervous symptoms are legion, being largely reflex 
manifestations similar to those of the various uterine dis- 
eases — nervous irritability, hysteria, hypochrondriasis, 
melancholia, etc. In some cases they become so pro- 
nounced as to cause hallucination of sight, hearing, and 
may even produce insanity. Sleep is disturbed or there 
may be complete insomnia; many find it impossible to lie 
on the left side. The reason for the reflexes is, as yet, un- 
known. Kdebohls believes they, with many of the digest- 
ive symptoms, are due to pressure upon the solar plexus 
of the sympathetic nervous system. Changes in the circu- 
lation with almost complete cyanosis, and a sensation of 
constriction in various parts of the body, and great pain in 
the hands and fingers, are often present. 

The stomach and duodenum are frequently dislocated 
and distended with gas. Pain, often burning in character, 
is quite constant and may be felt in the region of the kid- 
ney, or more frequently along the free border of the ribs 
of the corresponding side. The mouth may be ulcerated, 
the gums spongy, and the tongue thick, red and sore, 



140 UROPOIETIC DISEASES. 

showing the imprints of the teeth. There may be consti- 
pation or alternating diarrhoea and constipation, and at 
times pieces of membrane or fibrous masses, from one- 
eighth to two inches in length, are passed with the stool. 
Patients sometimes complain of a sensation as if some- 
thing were alive in the abdomen. 

The lumbar region corresponding to the movable kid- 
ney is often somewhat hollowed, and may be tym- 
panitic instead of flat on percussion. The kidney may 
appear as a tumor, resembling in form a normal kidney, 
below the free ribs on the anterior portion of the abdomen, 
in the umbilical region, or even across the centre of the 
addomen. This tumor slips easily from beneath the fin- 
gers, and if the patient assumes the dorsal position it can 
usually be replaced in its normal location, and the tym- 
panitis on percussion in the lumbar renal region will 
give place to flatness. It should, however, be remem- 
bered that the normal kidney has a range of motion of 
three -fourths to one inch in a vertical direction, and that 
the term movable kidney can only be applied when it ex- 
ceeds this limit of mobility. In the very fat it is some- 
times impossible to make a diagnosis by the physical 
signs. 

The pain, nervous and dyspeptic symptoms caused by 
a movable or floating kidney have frequently been 
attributed to a diseased ovary and that innocent organ 
has been removed without cause and without relief to the 
unhappy patient. 

In the female, the symptoms are all worse during the 
menstrual period and during the first one or two months 
of pregnancy; due to the heavy and prolapsed uterus drag- 
ging down the kidney and other abdominal organs. As 
pregnancy advances or tumors develop and push up the 
abdominal viscera, relief from the symptoms frequently 
occur. 



NEPHROPTOSIS. 141 

The clinical history varies somewhat with the kidney 
involved. If it is the right, flatulence, indigestion and 
vomiting will be prominent symptoms. The indigestion 
will not depend upon the character of food taken, and the 
pain accompanying it usually appears about two hours 
after eating. The pain and disturbed indigestion are 
caused by a mechanical kinking in the duodenum from 
the sagging of the displaced kidney when the connecting 
band of tissue is firm ; when it is loose the symptoms may 
be very slight. These gastric crises resemble those occur- 
ring in stricture of the pyloric end of the stomach and 
differ greatly from the renal crisis caused by the twisting 
of the ureters. When the left kidney is involved, the 
gastric symptoms are absent and constipation is a promi- 
nent symptom. 

In a paper on this subject, Dr. A. H. Cordier, Medical 
Record, 1896, draws the following deductions: (1) A 
movable kidney often produces a dilatation of the stomach 
with all the accompanying symptoms of disease of that 
organ. (2) It is a fruitful source of gall-stones, because 
of the pedicle producing a partial obstruction of the com- 
mon duct. (3) The bending of the ureter often gives rise 
to hydro-nephrosis ; this, in turn, is sometimes converted 
into pyo-nephrosis. (4) It may produce death by strangu- 
lation from torsion of the vessels and ureter. (5) By 
dragging on the abdominal aorta and kinking the vena 
cava, a condition simulating an aneurism of the vessels 
may be produced. (6) Pain, which is referred to the 
region of distribution of the spinal nerves, is often induced 
by a movable kidney through disturbance of the ab- 
dominal brain. (7) General nerve exhaustion often re- 
sults from interference with digestion, assimilation and 
elimination. 

Diagnosis. — In examining a patient for movable kid- 
ney, three positions are recommended. First : The patient 



142 UROPOIETIC DISEASES. 

is placed in the dorsal position with the shoulders ele- 
vated, thighs flexed upon the abdomen and instructed 
to make deep inspirations and expirations to relax the 
abdominal muscles. The hand of the surgeon is placed 
under the hollow of the loin, between the last rib and 
the crest of the ilium, the thumb encircling the abdo- 
exmen immediately below the costal arch but without 
ercising pressure. As expiration is about to commence, 
the thumb is pressed upward beneath the costal arch 
and as deeply as possible toward the kidney, at the 
same time the kidney being brought forward by the 
pressure of the fingers from behind. If the patient is not 
too fleshy, a dislocated kidney may be made out by placing 
the other hand below the thumb and demonstrating its 
abnormal mobility. When the kidney lies entirely in 
the grasp of the hand it is pathologically movable. As 
the grasp is relaxed, the kidney is liable to slip back into 
its normal position. Deep pressure frequently causes a 
sickening, nauseated feeling. A kidney that descends only 
so that its lower half can be felt on inspiration and re- 
cedes with expiration is to be considered as physiologically 
movable. If the mobility cannot be determined in the 
dorsal position, the patient should recline on the side op- 
posite to that in which the kidney is to be examined; 
then by bimanual examination during deep inspiration, as 
above, the diagnostic points may usually be demonstrated. 
These methods are objectionable because the position of 
the body facilitates the return of the kidney to its normal 
position, and in patients who are very fleshy it is im- 
possible or very difficult. When, however, the patient 
stands with the shoulders bent forward, the kidney will 
be strongly displaced and can usually be mapped out 
with the finger as it presses against the abdominal wall. 
A floating or movable kidney must be differentiated 



NEPHROPTOSIS. 143 

from growths in the mesentery, cancer of the intestines, 
the pancreas, a wandering spleen, a diseased gall-bladder, 
an ovary, etc. These can usually be eliminated by 
the clinical history. An enlarged gall-bladder, when 
mobile, moves in a circle, and, when distended with gall- 
stones, is hard and more tense than a movable kidney. 
The accompanying jaundice will assist in the diagnosis, 
although an exploratory incision is sometimes required to 
make it clear. 

Treatment. — The kidney must be restored to its normal 
position and properly supported. The administration of 
the indicated remedy should not be neglected, because 
there is a surgical condition present. Those most fre- 
quently indicated are : Strychnia ars., Pulsatilla, Sulphur, 
Ignatia, Gelsemium and Lachesis. In the renal crisis, rest 
in the dorsal position with hot formentations or baths are 
valuable adjuvants. Sometimes morphia may be required. 

There are four methods of treating chronic cases : First, 
absolute rest in every sense of the word. No carriage, 
bicycle, or train rides and no walking, climbing, jumping, 
dancing, etc., can be indulged in during the treatment. 
Few patients, however, can afford to remain absolutely 
quiet. Next in order is a proper belt or bandage. New- 
man uses a rubber pad which is inflated after adjustment. 
Others recommend elastic webbing, passing it completely 
around the abdomen. This acts well in males and in 
females who are free from uterine disorders. A simple, 
broad bandage, with a broad pad, is sometimes very satis- 
factory. A tight corset or a spring truss, with a large 
pad to compress and push upward the low r er part of the 
abdomen, have also been advised. Of the various kinds of 
supports, the best satisfaction has been given by a silk 
abdominal belt, with perineal straps to retain it in position, 
as described by Dr. W. W. Stewart, in the Medical Record, 
Feb. 9, 1895. In some cases a pad of horse-hair or wool, 



144 



UROPOIETIC DISEASES. 



covered with kid, and placed just below the kidney, will 
be required to retain the displaced organ in its normal 
position. 

The greatest care is necessary in taking the measure- 
ments from which the belt is to be made. These measure- 
ments are taken at eight distinct points, as per Fig. I. 

life - : *■ 




Fig. i. 
The patient should stand squarely on the feet while they 
are taken, and the tape should be drawn uncomfortably 
tight at each point. The belt should always extend as 
high as the last rib and fit snugly. 

Dr. S. A. Newhall, in the Kansas City Medical Arena,, 
records a case cured by faradism, one pole being applied in 
the vagina and the other over the kidney region. An 
application was made daily, and after the third the kidney 
returned to its normal position and remained there. The 
electric treatments were continued daily for two weeks,. 
and then every second day for another two weeks. In 
many cases excellent results are obtained with faradism,. 
combined with a proper abdominal bandage and the usual 
hygienic restriction. Mechanical massage of the abdom- 



NEPHROPTOSIS. 145 

inal muscles and organs have been successful in restoring 
and keeping the kidney in its normal position. When 
these means are not successful, and the kidney is healthy, 
a nephrorrhaphy must be performed, and the organ fixed 
to the posterior wall of the abdomen ; if diseased, it 
must be removed (see nephrorrhaphy-nephrotomy). Bruce 
Clark says that movable kidneys tend to the development 
of calculous deposits in the pelves of the kidney, interstitial 
nephritis, etc. and advises early operation. Osier says that 
operation is not always successful. 



10 



CHAPTER XII. 
URETERAL INJURIES AND FISTULA. 

RUPTURE OF THE URETER. 

Etiology. — The ureters are so deeply situated in the 
abdominal and pelvic cavities and so well protected by the 
bony and muscular walls behind and the abdominal 
viscera in front that injury can hardly be expected without 
instant death resulting. Cases are now and then reported 
where the ureter has been ruptured by violence applied to 
the front of the body, by gunshot wounds, by injury to 
the internal mucous lining from calculi passing through it, 
or it may be accidentally punctured by the surgeon. These 
may all result in stricture and occlusion of the duct. 

Clinical History. — Rupture of the ureter may present 
no immediate symptoms ; if present, they may be masked 
by other general symptoms or conditions. Collapse, 
hemorrhage into the surrounding parts, with extravasation 
of urine, usually non-irritant in character, accompanied 
by the passage of blood-stained urine, etc., may follow. 
Rupture generally occurs at or near the junction of the 
ureter with the pelvis of the kidney, thus differing greatly 
in location from rupture of the bladder. When it happens 
a large quantity of urine deficient in urea soon accumulates 
in the cellular tissues behind the peritoneum and cause a 
swelling on that side of the abdomen which may extend 
into the loin or to the iliac fossa. The fact that this effu- 
sion of urine into the cellular tissue does not produc sup- 
purative changes is remarkable and deserves notice. Har- 



RUPTURE OF THE URETER. 147 

rison has advanced the theory that rupture of the ureter 
stops the secretive function of the kidney and allows only 
the process of exudation to continue ; hence, the deficiency 
of urea and absence of anything to cause ammoniacal de- 
composition. 

la the ureter, as in the urethra, traumatisms tend to 
strictures which lead to occlusion of the duct, hydrone- 
phrosis, and, finally, atrophy of the kidney. When, how- 
ever, the injury involves the peritoneum, shock, peritonitis 
and death are not long delayed. 

Treatment. — This depends upon the conditions present. 
If the peritoneum is involved, a laparotomy and possibly a 
nephrectomy will be indicated. When there is fluid in the 
cellular tissue behind the peritoneum, its repeated removal 
with the aspirator has been satisfactory and recovery has 
been rapid ; but if there is hemorrhage, a lumbar explora- 
tory incision must be made immediately, the divided ends 
of the ureter found, properly united and the vessels ligated. 
All operations on the ureter above the point where it 
crosses the iliac artery should be retro-peritoneal, except 
when injury to it occurs during a laparotomy. The pelvic 
portion may be operated upon through the vault of the 
vagina, the rectum or perineum. Surgical operations are 
also indicated when, after injury to the ureter, it is believed 
that a stricture has formed, and Kelly's probe proves its 
existence. The latest operation for stricture or rupture of 
the ureter is Van Hook's method of ureteral anastomosis. 
The ruptured or severed lower end is tied with silk or cat- 
gut, and a longitudinal incision is made in the segment 
below the ligature, and into this is pressed the end of the 
upper segment, which may be anchored in with a cat-gat 
suture. When the ureter is only partially divided, the 
wound should be extended longitudinally and sutured 
transversely to compensate for anticipated stricture. Al- 
though in many cases good results from suturing the 



148 UROPOIETIC DISEASES. 

ureter into a loop of the intestine have been obtained, 
there are many objections to the operation, chief among 
them being that it allows free passage for the bacilli coli 
communi from the intestine to the pelvis of the kidney. 
Borri, Polyclinico, No. 19, 1895, reports many experiments 
along this line on dogs ; in two cases, he made a length- 
wise incision in the intestine and connected the ureter 
with it by means of a button similar to the Murphy's but- 
ton, with a tube inserted into the ureter ; the buttons 
came away in from nine to twelve days ; the experiments 
were both successful. Rydygien and Van Hook, in cases 
when the ureter is cut by the surgeon, advise bringing out 
both ends through the abdominal walls and allowing the 
wound to close about them. When the wound has united 
an artificial channel of skin is to be formed by making paral- 
lel incisions between the two openings and suturing the 
isolated integument to form a tube to connect the open ends. 
After union has taken place in this tube, the ends of the 
ureter are sutured to it and the whole depressed by sutur- 
ing the skin of the two opposite sides over it. 

URETERAL EISTUI^E. 

Ureteral fistulse sometimes occur; they may open ex- 
ternally into the lumbar region, on the abdomen, in the 
groin, or communicate with the rectum, bladder, stomach, 
vagina or uterus. Fistulse may be direct or irregular in 
their course. They may be caused by ulceration, due to 
tubercular or cancerous growths, calculi or other foreign 
bodies, but more commonly are the result of gynaecological 
operations. 

In ureteral fistula, there is a continuous or intermittent 
discharge of urine which is usually normal in character. If 
the opening in the ureter is near the kidney the flow will 
be continuous ; if near the lower extremity of the ureter, it 
will be intermittent. 

Treatment. — As advised for ureteral injury. 



CHAPTER XIII. 

DISEASES OF THE URETERS. 

URETERITIS. 

Etiology. — True ureteritis is almost invariably caused 
by infection, either ascending from the bladder by 
gonorrhoeal extension ; descending, as in tubercular 
lesions ; hsematogenous, or from contiguity of tissue in 
periureteral cellulitis, etc. Congestion of the ureter from 
traumatism, the presence of tumors, over-distension from 
any cause, or irritation by the urine, etc., predispose to it. 

Clinical History. — A true pathognomonic history has 
not as yet been formulated, the symptoms varying with 
the exciting cause and the severity of the inflammation. 
The one symptom that has been recognized is tender- 
ness and soreness of the ureter on palpation. The in- 
flammatory swelling may greatly encroach upon and re- 
duce the calibre of the canal, and if the^ walls of the 
ureter are greatly involved a strictured condition may 
result. 

Treatment. — The remedies are those indicated for the 
cystitis, pyelitis, etc., causing it. See chapter on thera- 
peutics. The diseased ureter may be catheterized and 
douched with Nitrate of silver, i to 2,000 ; Permanganate 
of potash, 1 to 5,000, etc., as indicated. Internal disinfec- 
tion by physiological doses of Boric acid, Salol, Oil of Euca- 
lyptus, Uro tropin, etc., has been satisfactory. When the 
disease is an accompaniment of suppuration or any other 
disease of the kidney requiring a nephrectomy, relief of the 



150 UROPOIETIC DISEASES. 

symptoms can sometimes only be obtained after the ureter 
as well as the kidney have been removed. This is espe- 
cially true when the ureteritis is of tubercular origin. 

URETERAL OBSTRUCTION. 

Stricture of the ureter may occur at any point. In the 
majority of cases reported, the occlusion has been located 
near the bladder. All narrowed conditions are not 
strictures. The ureter, which is from ten to fifteen inches 
in length, has three normal contractions ; the first is about 
T.y 2 to 2 inches from the pelvis of the kidney; the second 
at the junction of the pelvic and vesical portions, and the 
third at the point where the ureter crosses the iliac artery. 
There are also a number of thin-walled semi-lunar valves, 
situated transversely to the ureter, opening upwards, one 
or many of which may become enlarged and obstruct 
the urinary flow or retard the passage of a calculus. 
Strictures may occur at any point along the ureter, from 
cicatrization of a tubercular ulcer, from ulcerations pro- 
duced by the passage of a calculus or possibly from the 
extension of a gonorrheal inflammation. The most frequent 
cause, however, of ureteral obstruction is the lodgment of 
a calculus in the canal, which may even completely 
occlude the duct. When complete, it results in a hydro- 
or pyo-nephrosis, which may finally cause atrophy of the 
kidney of the affected side. When the kidney and ureter 
of the opposite side are in a normal condition, it may 
occur without giving rise to any special symptoms. It 
may, however, be suspected, after an attack of renal colic, 
accompanied by hsematuria, etc., if the pain gradually 
becomes confined to one point, and the blood in the urine 
largely or completely disappears, especially when pressure 
along the ureter at a special fixed point. If the ureter 
and the kidney of the opposite side are normal, these 
organs undergo hypertrophy, and unpleasant symptoms 



URETERAL OBSTRUCTION. 151 

are rarely experienced ; but, if the ureter has been 
obstructed at some previous time by a calculus, a stric- 
ture, by pressure of new growths, by displacements, 
etc., or the kidney itself has been incapacitated, removed, 
or was undeveloped, the symptoms will then assume a 
very serious nature, namely, obstructive suppression of the 
urine. Sir William Roberts says: " When suppresion is 
complete, the patient may live from nine to eleven days." 
Sir James Paget records a case of total suppression of 
twenty-one days' duration, with only one day on which 
urine was voided. The suppression may be partial or 
complete, varying with the size and contour of the calculus 
or tumor, etc. If complete, a hydronephrotic tumor 
develops on the side obstructed, giving a slight increased 
fullness to the renal region, uraemia develops and death 
follows. In some of the cases reported no symptoms 
appeared except suppression of the urine following the 
renal colic. In all cases of complete suppression, time is 
valuable, and a diagnosis must be correctly made and 
surgical relief given at once, or the patient will soon die. 
The ureters should be examined with Casper's ureter- 
cystoscope, or by the Kelly method. When possible, 
Kelly's wax probes should be used to verify the diag- 
nosis, and the patient should also be examined for tumors, 
displacements, etc. 

Treatment. — For symptomatic treatment see chapter 
on renal therapeutics. Hot fomentations should be 
applied to the painful parts. Hot baths and massage 
are frequently of much benefit. Intra-vesical in- 
jections of warm, antiseptic solutions have in some 
cases apparently over-distended the lower part of 
the ureter and assisted the obstruction to pass into the 
bladder. When these methods fail, surgical measures 
must be resorted to. First, an exploratory incision should 
be made to ascertain if a calculus blocks the opening of 



152 UROPOIETIC DISEASES. 

the ureter at its exit from the pelvis of the kidney. If not 
a nephrolithotomy may be indicated. The ureter should 
be suitably explored with a steel, 4 to 12 F. bulbous 
bougie. This may dislodge the obstructing calculus, which 
will pass down the ureter into the bladder. If the cal- 
culus is not dislodged, the surgical treatment will de- 
pend upon the individual case. A renal fistula can be 
established through the lumbar legion, into the vagina, 
or into one of the small intestines. If one ureter 
only is obstructed, and the other, with its kidney, is nor- 
mal, the question of nephrectomy should be considered, 
providing the obstruction cannot be removed. When the 
calculus causing the obstruction is situated near the bladder 
opening, it may sometimes be discovered by digital exami- 
nation through the vaginal walls and surgically removed 
by that route. Again, the calculus may project into the 
bladder, being fixed in the orifice of the ureter, and may 
be disengaged by the Thompson stone searcher or the end 
of a cystoscope. In all operations on the ureter it must 
always be incised longitudinally to avoid subsequent 
stricture. 



CHAPTER XIV. 

DISEASES OF THE PELVIS OF THE KIDNEY. 

PYELITIS. 

Pyelitis is an inflammation of the pelvis and the calices 
of the kidney with the involvement as a rnle of the 
proximal end of the ureter. 

Etiology. — One or both pelves may be affected. When 
but one pelvis is involved, it is usually owing to ob- 
struction of its ureter, the inflammation may be local ; 
when both are involved, it is usually the result of 
constitutional disorders, diseases of the bladder or pros- 
tate, stricture of the urethra, etc. Pyelitis may be pri- 
mary or secondary, acute or chronic. 

Acute primary pyelitis occurs during the course of the 
infectious diseases, i. e., typhus, typhoid, pyaemia, influ- 
enza, cholera, diphtheria, scurvy, scarlet fever, measles, 
etc. It may be caused by the chemical presence of certain 
drugs, i. e., Cantharides, Turpentine, Copaiva, Sandal 
wood, and some of the diuretics ; by mechanical pressure 
as in hydro-nephrosis, from infection by bacteria from 
the colon, or the result of exposure to damp and cold. 

Chronic primary pyelitis is classified as traumatic, cal- 
culous and tubercular. Traumatic pyelitis is of mechani- 
cal origin, occurring with or without ureteral obstruction. 
Tubercular pyelitis is dependent upon tubercular growths 
in the pelvis of the kidney. Calculous pyelitis is pro- 
duced by the presence of a calculus in the pelvis of the 
kidney. If it can be dissolved or dislodged, the case can 
be cured ; otherwise the symptoms of pyelitis will gradu- 
ally become more distressing. 



154 UROPOIETIC DISEASES. 

Acute secondary pyelitis is usually due to an ascending 
gonorrhoea, or a simple cystitis. 

Chronic secondary pyelitis may be caused by obstruction 
of the urinary flow by strictures of the urethra, an enlarged 
prostate, a chronic cystitis, pressure of tumors on or a 
retained stone in the ureter, to irritating crystals in the 
urine from lithaemic or gouty conditions, or chronic 
catarrhal conditions resulting from altered metabolism, 
occurring especially in paraplegia and other forms of spinal 
disease. 

Pathological Anatomy. — Acute primary pyelitis, in 
the milder cases, may be simply a congestion of the 
mucous membrane of the pelves and calices, and a simple 
swelling of the surface epithelium. In the more severe 
cases, the mucous membrane is coated with an exudate of 
fibrin and pus. The bacteria of suppuration may be 
present, and the suppurative inflammation may invade the 
kidney tissue, giving rise to a suppurative nephritis. 

In chronic primary pyelitis the mucous membrane of 
the pelves and calices is thickened, the epithelium is 
swollen and necrotic and the inner surface of the pelvis is 
covered with pus, fibrin and dead epithelium. 

In acute secondary pyelitis the inflammation may be 
directly continuous with that of the lower urinary passages, 
or the ureter may be intact. 

The mucous membrane may be simply congested, with 
swelling of the epithelium, or there may be an exuda- 
tion of serum, fibrin and pus, with swelling and death of 
the epithelium. 

In chronic secondary pyelitis there is a thickening of 
the mucous membrane of pelves and calices, the epithe- 
lium is swollen and granular and there is a growth of 
granulation tissue beneath the epithelium. When there 
are tubercular growths in the pelvis, there is in addi- 



PYELITIS. 155 

tion a more or less diffuse exudative inflammation. The 
exudate contains tubercle bacilli. 

Clinical History. — In general there is pain referred to 
the lumbar region of one or both sides, with tenderness 
and soreness on deep pressure. The pain follows the 
course of the ureters, shoots into the perineum and thigh, 
and is accompanied by frequent and painful micturition. 
The urine usually contains pus, and may be acid or alka- 
line in reaction ; tailed epithelium may be found, but their 
absence does not contra-indicate pyelitis. The general 
symptoms are such that the pyelitis is frequently over- 
looked in making a diagnosis. It is always important to 
differentiate between primary and secondary pyelitis. 

Acute primary pyelitis may be so slight as to escape 
notice, or, if. present, is of slight importance compared 
with the exciting cause. There may be chill, fever, in- 
tense pain in the region of the kidney, with scanty, puru- 
lent and albuminous urine, with an accompanying in- 
volvement of the kidney tissue (a true pyelonephrosis). 
This is a very severe form of the disease and is usually bi- 
lateral. 

Chronic primary pyelitis develops slowly and insidi- 
ously, though it sometimes is the immediate result of a 
blow or fall upon the lumbar region. There is aching and 
uneasiness in the renal region, which at first may be transi- 
tory, accompanied by some tenderness and soreness on 
deep pressure. 

The urine gives an acid reaction (differing from the 
alkaline urine of cystitis) with a specific gravity of about 
1,030, containing blood, pus- corpuscles, mucus, tailed 
epithelium, etc. As the disease advances the pus in- 
creases in quantity and the epithelial cells gradually disap- 
pear from the urine. The pus does not collect in masses 
or become ropy, but remains separated, giving a turbid 



156 UROPQIETIC DISEASES. 

appearance to the urine ; on standing it settles to the bot- 
tom of the vessel. 

When the pelvis of the kidney is sacculated, the urine 
may become ammoniacal and very offensive, being fouled 
easily from the adjacent colon or by sepsis of the bladder, 
occasioned by surgical uncleanliness, and the pus, which, 
up to this time, has been mixed with the urine, rapidly 
separates from the acid urine, and becomes thick, solid, 
and stringy. 

The microscope may reveal crystals of ammoniaco- 
magnesian phosphates, irregular and worm-eaten from 
contact with the acid urine. The most characteristic 
symptom, however, is an acid urine containing a vari- 
able quantity of pus, with a painful, tender and swollen 
kidney, which possibly gives evidence of fluctuation. 
Sometimes the breath and perspiration will exhale the 
peculiar odor of ammonia. In these cases urethral in- 
strumentation is contra-indicated. The amount of albumen 
varies according to the quantity of pus and blood present 
in the urine. In pyelitis, when the ureter is free through- 
out its whole extent, pus will be constantly present in the 
urine, but if it becomes obstructed a tumor may be devel- 
oped between the crest of the ilium and the last rib, giv- 
ing a slight prominence to the affected side. When the 
obstruction is removed this tumor disappears and large 
quantities of pus are discharged with the urine. 

In chronic pyelitis there is fever, emaciation and weak- 
ness, often chill, fever and sweat (hectic) occurring at reg- 
ular intervals, generally in the evening. This is especially 
true in conditions of pyonephrosis from occlusion of the 
ureter. When the pelvis of only one kidney is affected 
the kidney structure sometimes becomes absorbed from 
pressure or disease and an encysted collection of pus re- 
sults. 

Traumatic pyelitis varies with the severity of the trau- 



PYELITIS. 157 

matism. If the injury has been slight, it may be followed 
by a little haetnaturia and few or no symptoms, or, again, 
pus may appear in the urine together with all the 
symptoms of pyelitis. The majority of cases soon recover, 
others become chronic and removal of the diseased organ 
may be required. 

Calculous pyelitis is caused by the presence in the pelvis 
of the kidney of one or more calculi. Women seem 
more prone to this disease than men. It may be present 
with pyuria for years without producing symptoms or 
change in the size of the kidney. Pain in the kidney 
region is common ; it may be intermittent, moderate or 
excruciating. There are at times sharp, twinging pains 
occasioned by the stone partly engaging itself in the 
opening of the ureter. Symptoms may be absent until 
long after pus has been found in the urine. As the case 
progresses the kidney increases somewhat in size, due to 
the swollen condition of the kidney and pelvis or to 
retained fluid. Haematuria may accompany the pyuria. 
If an acute pyelitis is in any way added to the chronic 
condition the attack is usually severe. 

Tubercular pyelitis is in fact a true pyonephrosis, or 
soon becomes one. It may remain sub-acute in character, 
giving rise to little pain or fever ; the urine is acid in re- 
action, laden with pus, albuminous, of low specific gravity, 
and generally contains tubercle bacilli.. 

Secondary pyelitis is undoubtedly the most frequent 
form of pyelitis and the least frequently recognized. It is 
due to an ascending inflammation along the ureter to the 
pelvis of the kidney from disease or to obstruction in the 
bladder, prostate or urethra. 

Acute secondary pyelitis is fortunately rare. It usually 
terminates fatally. It is caused by some injudicious instru- 
mentation of the genito-urinary tract in patients suffering 
from prostatic disease or tubercular cystitis, especially in 



158 UROPOIETIC DISEASES. 

those past the fiftieth year in whom the lithaemic condition 
is well marked, or by the sndden removal of the urinary 
pressure of a hydronephrosis. 

A tubercular bladder is very intolerant of instrumenta- 
tion ; in the early stage of the disease ; the male bladder 
is less tolerant than the female. Washing of the bladder 
in this class of cases has caused acute ascending pyelitis, 
which announces itself sometimes within two hours after 
the instrumentation by a rise in temperature, etc. There 
fore, instrumental examination of an inflamed bladder 
with an associated nodular or tubercular prostate must 
never be attempted without proper care and deliberation. 

In iithaemia, the mucous membrane of the pelvis of 
the kidney and ureter is constantly eroded and irritated by 
the excess of urates which passes over it, and conse- 
quently is not in a condition to stand sudden shock or 
inflammatory invasion. Instrumentation, unless carefully 
made, under the strictest asepsis, may quickly light up a 
severe and fatal pyelitis. In the aged, urinary obstruction 
from an enlarged prostate produces first a dilated and 
sacculated bladder, and finally a hydronephrosis ; slow 
continued pressure is made on the secreting tissues of the 
kidney, and the urine simply strains through. Digestive 
disturbances and weakness usually accompany the condi- 
tion. In this disease, the sudden removal of the urine may 
result in acute congestion of the pelvis of the kidney and 
death in from five to ten days from acute pyelitis. 

When acute secondary pyelitis is the result of an ascend- 
ing gonorrhoea, the pyelitis is usually sub-acute in charac- 
ter and rarely fatal ; in the tubercular variety it is usually 
unilateral. Acute secondary pyelitis is characterized by a 
sudden rise in temperature, with a dull pain in the lumbar 
region, increased frequency of micturition, the urine being 
thick, cloudy and acid in reaction ; in some cases it 
becomes rapidly suppressed. 



PYELITIS. 159 

Chronic secondary pyelitis probably accompanies nearly 
all chronic diseases of the urinary tract. Clinical symp- 
toms are few and will depend upon the severity and dur- 
ation of the vesico-urethral obstruction. 

Prognosis. — Acute secondary or ascending pyelitis 
usually results in death unless the offending organ is 
removed ; many cases of the acute variety escape recog- 
nition. 

Secondary pyelitis may recover without surgical inter^ 
ference, but it must be remembered that some remain 
in a quiescent state for years, when suddenly, without 
any apparent cause, an acute pyelitis develops, recognized 
by the chill, fever, thirst, vomiting, extreme pain in 
the lumbar region, etc., followed by death in a few hours 
or days. 

Treatment. — In acute cases, Aconite, Veratrum vir., 
Belladonna, Rhus tox., Cantharides, Cannabis sat. or 
Bryonia alb. may be indicated ; in the more chronic cases, 
where there is an excessive catarrh of the mucous mem- 
brane of the pelvis, Chimaphila umb., Berberis vulg., 
Pareira brav., Uva ursi, Benzoicum ac, Sulphur, Pulsatilla, 
Buchu, Sepia, Hydrastinin sulph. and mur., Stigmata 
maidis, etc., will be required, according to their special 
indications. See chapters on vesical and renal therapeutics. 

In acute primary pyelitis, the remedies applicable to the 
general condition will usually fully cover this complication. 
Ill-advised treatment or an unnecessary examination has not 
infrequently rekindled a latent tubercular or other inflam- 
matory condition, and produced an acute ascending pyelitis, 
suppression of the urine and death. Hence, in suspicious 
cases, the first examination with instruments should be 
made only after forty-eight hours' rest in bed, with general 
internal disinfection of the urinary tract by the adminis- 
tration of Boric acid, Urotropin, Oil of Kucalytus, Benzoate 
of soda, Salol or Naptholin in physiological doses. 



160 UROPOIETIC DISEASES. 

In severe cases, true pyelonephrosis, surgical treatment 
is of no avail. The remedies most frequently required, 
and which have been brilliantly successful in some cases, are 
Aconite, Veratrum vir., Belladonna, Hepar sulph., Hekla 
lava, Sodium sulph. carb., etc. 

In acute pyelitis, the patient must remain in bed, with 
hot poultices or fomentations applied to the kidney re- 
gion. Dry cups are sometimes required. Foot baths, hot 
air baths or general hot baths are recommended. Milk is 
the ideal diet. Stimulating and irritating food must be 
avoided. In acute primary tubercular pyelitis, a ne- 
phrectomy is always indicated ; it is sometimes necessary 
in the acute ascending variety. In the chronic forms due 
to obstruction, surgical relief will be required only when 
they are of tubercular or lithaemic origin. Drainage of 
the bladder by perineal section is frequently of great 
benefit. Distilled and alkaline mineral waters, Boric 
acid in doses of ten grains three times daily ; Salol, five 
grains after each meal; Urotropin in 7^ grain doses, 
or Saccharin, three times a day, must not be forgotten* 
When the disease is caused by calculi the administration 
of Plydrangea, Lycopodium, Silicea or Piperazine for the 
uric acid form, and Magnesium boro-citrate when the 
calculus is composed of phosphates and oxalates, has often 
cured. If the calculi are not dissolved and the indicated 
remedy fails to give relief ; if the condition of the patient 
permits it a nephrotomy must be performed ; if an abscess 
has formed and pointed an operation should be made at 
once. First, some of the pus should be withdrawn with 
the aspirator, then the abscess cavity opened freely and 
dress antiseptically. In this operation there is no danger 
of perforating the peritoneum, as the kidney is outside and 
behind it. 

Kelly, of John Hopkins Hospital, reports the successful 
treatment and cure of pyelitis by douching the pelvis of 



HYDRONEPHROSIS. 161 

the kidney after catheterization of the ureter, using the 
usual Boric acid, Nitrate of silver or Bi-chloride solutions. 
After introducing the ureteral catheter, he uses suction by 
means of a syringe to draw down the thick pus, small 
calculi, etc., from the pelvis of the kidney before using the 
pelvic douche. 

HYDRONEPHROSIS. 

When the pelvis of the kidney is over-distended with 
liquid, usually urine, the condition is called hydronephrosis. 

Etiology. — It may be congenital or acquired, permanent 
or temporary. The causes are numerous though some- 
times undiscoverable, the most frequent being obstruction to 
the natural exit of the urine. When this obstruction is 
above the bladder it produces hydronephrosis of one side 
only ; when below, it will affect the pelves of both kid- 
neys. Occlusion or absence of one or both ureters is the 
usual congenital cause. A calculus, a blood clot, a mass of 
pus or any other foreign matter obstructing the ureter may 
permanently or temporarily close the ureter ; sometimes a 
calculus acts as a ball valve. Tumors or growths of various 
kinds, either within, upon, or external to the ureter, will, 
by impingeing upon the calibre of the canal, produce 
this condition. It is also due to retroflexion of the 
uterus, cicatricial tissue originating either from local in- 
flammations, the result of surgical operations or injuries 
caused by the passage of calculi through the ureter ; from 
twists and loops in the ureter, or from a movable or float- 
ing kidney. The abnormal origin of the ureter in the 
pelvis of the kidney, or when inserted into the bladder 
obliquely, may produce a valve-like opening, which, under 
certain conditions, obstructs the natural flow or exit of 
the urinary secretion, and produces a hydronephrosis. The 
causes of double hydronephrosis are polyuria, obstructions 
in the bladder, i. e., large stones, tumors within, upon and 
11 



162 UROPOIETIC DISEASES. 

external to the bladder, enlarged prostate, stricture of the 
urethra, and cancerous or other growths at any point on or 
adjacent to the genito-urinary tract. 

Pathological Anatomy. — The ureters are dilated and 
their walls hyper trophied. They are sometimes sacculated 
and as large as the small intestines. The pelvis of the kid- 
ney on the affected side is dilated, sometimes enormously so,, 
forming a large cystic tumor. The calices are each dilated r 
forming cysts. The kidney tissue immediately surround- 
ing the dilated portions is flattened. The rest of the kid- 
ney may undergo interstitial inflammation and pyelo- 
nephritis may be the result. The dilated portions contain 
urine or, if suppuration has taken place, the urine may be 
mixed with pus. 

Clinical History. — If congenital and bi-lateral it is 
rapidly fatal. The acquired form occurs more frequently 
in the male than the female. The subjective symptoms 
are often wanting or are very obscure, and many patients 
with this condition live for twenty or thirty years without 
special inconvenience. Occasionally a hydronephrotic sac 
empties itself and spontaneous recovery occurs ; but us- 
ually it slowly increases in size. A large hydronephrotic 
tumor is uncommon. There is uneasiness and fullness re- 
ferred to the affected loin and lumbar region, which may 
appear somewhat full and more distended than the oppo- 
site side. When large, the tumor may press on the lower 
part of the alimentary canal and cause constipation, or 
against the diaphragm and thoracic viscera and produce 
dyspnoea. It rarely causes death unless complicated by or 
associated with some other disease. When the abdominal 
walls are thin, the sac may be made out as an elongated 
somewhat kidney-shaped tumor. Usually it is not tender 
to the touch or to manipulation ; it gives fluctuation on 
palpitation and flatness on percussion unless it is covered 
by the colon or a coil of the small intestines, which may 



HYDRONEPHROSIS. 163 

happen if the disease has developed in a kidney previously 
movable or floating. 

Diagnosis. — Obstruction to the urinary duct has, in 
new-born infants, caused hydronephrosis and death. It is 
not necessary to have a complete obstruction to produce 
hydronephrosis. If the swelling in the loin and lumbar 
region disappears at times, followed by an unusual flow of 
urine, the diagnosis may be considered established. Some- 
times when it is very large a positive diagnosis is extremely 
difficult, as it may be mistaken for an ovarian tumor ; 
ovarian growths, however, increase in size from below up- 
ward, while the cyst produced by hydronephrosis increases 
from below downward. In hydatids of the liver or kid- 
ney, aspiration and examination of the fluid will gener- 
ally give sufficient evidence to establish a diagnosis. 
The hydatid cyst contains the characteristic hooklets ; 
the ovarian, the Graafian cells ; the cyst of hydronephrosis 
contains urea, cholesterin crystals and urine. In cancer- 
ous growths the cachexia, loss of strength, emaciation and 
fever will materially assist in the differential diagnosis. 

Treatment. — This varies according to the size of the 
cyst and the concomitant symptoms. When there is no 
discomfort, expectant methods, followed by gentle massage, 
have, in some cases, caused it to empty itself. If, however 
the distress becomes persistent, or it presses upon the 
neighboring organs, aspiration may become necessary. 
Sometimes successive aspirations result in a cure. On 
the right side, the aspirating needle should be introduced 
midway between the last rib and iliac crest, and on the 
left, at the anterior extremity of the eleventh intercostal 
space. Strict antiseptic precautions must be observed, 
as infection has been known to transform the hydro- 
nephrosis into a pyonephrosis; therefore, when frequent 
aspiration becomes necessary, it is preferable to incise and 
properly drain the cyst. When the hydronephrosis is the 



164 TJROPOIETIC DISEASES. 

result of obstruction by a calculus, an operation through 
the lumbar region, for its removal, will be required ; this 
in many cases has resulted in a urinary fistula, and, there- 
fore, many prefer a nephrectomy. 

PYONEPHROSIS. 

When the pelvis of the kidney is distended with pus, the 
condition is called pyonephrosis. 

Etiology. — The causes are similar to those of hydro- 
nephrosis. In the course of a pyelitis, if the ureter becomes 
obstructed, pyonephrosis develops. A calculus, which at 
first irritates the pelvis of the kidney, may cause inflamma- 
tion, and the discharge of pus, which may finally obstruct 
the ureter, with consequent retention of pus and urine. 
Tuberculosis of the kidney and its pelvis is another source 
of origin, the discharged cheesy mass obstructing the 
ureter. Injuries of various kinds, and especially the press- 
ure exerted during gestation, or from the uterus being 
pressed against the ureter or the pelvis of the kidney, may 
cause inflammation, formation of pus and obstruction. A 
hydronephrosis may be transformed into a pyonephrosis 
from careless aspiration for diagnosis or treatment, as 
well as rupture of an abscess in the kidney structure into an 
occluded pelvis, or the obstruction of the ureter by cheesy 
masses or blood clots. There are cases which are undoubt- 
edly due to invasion of the ureter and pelvis of the kidney 
by an ascending gonorrhoea, producing obstruction of the 
ureter and pyonephrosis. 

Pathological Anatomy. — The mucous membrane of the 
pdvis is thickened. It is covered with fibrin and pus, and 
there is a necrosis of the superficial layers of epithelium. 
If the condition has existed for a considerable length of 
time, it is apt to result in a suppurative nephritis, or a 
chronic interstitial nephritis. 



RENAL COLIC. 165 

Clinical History. — The general objective symptoms are 
similar to those of hydronephrosis, but, as the disease prog- 
resses, symptoms of sepsis appear and the renal region 
becomes sore and sensitive to touch. If pus is occasionally 
found in the urine, accompanied by a decrease in the full- 
ness of the affected side, the diagnosis will be easy. The 
abscess may open into the peritoneum and cause shock 
and death. It may discharge into one of the surrounding 
organs. The duration of this disease is from three months 
to three years. 

Treatment. — Attention must be given to the general 
building up of the system. In many cases drainage of the 
bladder has given great and permanent relief; nephrotomy 
or nephrectomy is only indicated when the disease is uni- 
lateral. If possible, the ureteral obstruction must be 
removed. Massage, with ingestion of large quantities of 
fluid, has in some recent cases been successful. If there is 
evidence of partial or complete obstruction of one Ureter, 
and constitutional symptoms of pus absorption appear, 
surgical relief as required by the individual case, i. e., 
aspiration, nephrotomy, or nephrectomy must at once be 
given. 

RENAL COLIC. 

Ureteric colic is caused by the passage of a renal calculus, 
a hydatid, a clot of blood or a collection of pus through the 
ureter, the pain varying greatly in severity and duration 
according to the condition of the ureter and the size and 
form of the body passing through it. 

Clinical History. — Renal colic may be moderate and 
continue only a few minutes or it may be agonizing 
and last for hours or days ; sometimes it is intermit- 
tent in character. The attack commences suddenly, 
although it may be preceded by some pain and uneasiness 
referred to the lumbar region of the affected side and ends 



166 UROPOIETIC DISEASES. 

almost as abruptly when the obstructing mass enters the 
bladder. When the foreign body engages at the opening 
of the ureter in the pelvis of the kidney it causes pain 
referred to the affected side. If, on the other hand, the 
foreign body becomes disengaged and passes back into the 
pelvis of the kidney the pain will cease for the time being, 
to return when it re-enters the ureter. 

The pain usually commences suddenly, increases in 
violence, follows the course of the ureter and shoots down 
the inner side of the thigh, to the end of the penis and into 
the scrotum, the latter being frequently retracted by the 
contraction of the cremaster muscle. The pain may radiate 
in various directions over the abdomen, to the breast or up 
the back ; it is paroxysmal, and so agonizing at times that 
it often, in nervous people, produces convulsions or syncope. 
As the attack increases in violence the patient rolls and 
twists from side to side and from one position to another 
in the endeavor to find relief. The face becomes pale, 
anxious, covered with perspiration, and the suffering is so 
great that it frequently causes the patient to scream and 
moan loudly. The pain continues between the paroxysms, 
but is less severe. There is an ineffectual desire to uri- 
nate, accompanied by burning, the urine being small 
in quantity and of dark color. Vomiting is of frequent 
occurrence. When the pain is very severe there may be 
rectal tenesmus and frequent unsatisfactory stools. Unless 
the pain continues for some time there is usually no rise in 
temperature or change in the pulse. If the foreign body 
becomes impacted in the ureter the intense pain may 
gradually subside and assume a gnawing character. This 
may disappear if the ureter dilates and allows the urine to 
pass the obstructing body, but when the ureter remains 
entirely occluded hydro- or pyonephrosis results. 

After passing into the bladder the calculus is usually 
expelled with the flow of urine during the next few hours. 



RENAL COLIC. 167 

t 

It may have produced great pain when passing through 
the ureter, but, if the urethra is normal, it may be voided 
with the urine without notice or pain. In order to ascer- 
tain the character of the foreign body which caused the 
colic, the urine must be carefully examined at each urina- 
tion until the obstructing body has been found. 

Prognosis. — This is always good unless impaction occurs, 
causing hydro- or pyonephrosis, etc. One attack pre- 
disposes to another. After the attack there is profuse 
micturition, and for some days the urine may contain 
blood. 

Treatment — Argentum nitricum : Nephralgia from the 
passage of renal calculi or congestion of the kidney ; dull 
aching pain across the back, extending into the bladder ; 
urine burns when voided ; dark urine containing uric 
acid, blood and renal epithelium. 

Berberis vulgaris : Renal colic ; sharp stitching pains 
radiating from the renal region in all directions, particu- 
larly downward and forward into the pelvis ; sharp dart- 
ing pains along the ureters ; urine has a reddish deposit 
composed of mucus, epithelium and lithiates. 

Calcarea carbonica : Has many reported cures when 
given in the higher potencies. 

Cantharides : Gravel in children, with irritating pain 
extending down into the penis, with constant pulling on 
that organ, also pain and congestion during the passage 
of renal calculi. 

Coccus cacti : Renal colic and hematuria ; lancinating 
pains extending from the renal region to the bladder ; 
urine contains large quantities of brick-red sediment, 
urates, uric acid, etc. 

Dioscorea villosa : Gravel, renal colic, pain shooting from 
kidney to bladder down into the testicles and leg, with 
cold clammy sweat over the body. 

L/ycopodium clavatum : Dull pain in renal region, re- 



168 UROPOIETIC DISEASES. 

• 

lieved by micturition ; renal colic, especially of the right 
side ; urine scanty, high colored ; red, sandy deposit com- 
posed of urates and uric acid ; urine sometimes contains 
mucus and pus, causing a whitish sediment. 

Nitric acidum : Renal calculi and colic ; the gravel is. 
composed mostly of oxalate of lime. 

Nux vomica : Renal colic or gravel ; pain extending 
from the renal region into the genital organs or leg> 
usually associated with intense and continuous backache i 
painful, ineffectual desire to urinate ; urine passed drop by 
drop, with burning, tearing pains at the neck of the 
bladder. Acts best on the right side. 

Pareira brava : Renal colic, with pains shooting down 
the legs ; violent pains into the glans penis, so intense that 
patient goes down on hands and knees to urinate ; urine 
contains red sandy deposit with much thick white viscid 
mucus ; urine ammoniacal. 

Pichi : Renal colic, lithiemia. 

Stigmata maidis : Renal colic, chronic pyelitis. 

Tabaccum : Renal colic with collapse from extreme 
pain. 

Thlaspi bursa pastoris : Renal colic, renal calculi with 
haetnaturia ; urine loaded with red crystals; has acted very 
satisfactorily in uric acid gravel. 

Uva ursi : Renal calculi and pyelitis. 

During the attack of colic, hot baths, sitz or general y 
hot fomentations or hot water bags placed over the seat of 
pain give great relief, relax the parts and facilitate the 
passage of the calculus. 

Alkaline waters in large quantities, Citrate of potash in 
20-grain doses, well diluted, every three hours, and light 
beers have been recommended to increase the flow of urine 
and so force the obstructing body onward. Change of 
position and manipulation of the parts often give relief and 
dislodge the mass. The inhalation of Ether or Chloroform 



RENAL COLIC. 169 

sometimes affords speedy relief. Suppositories of Opium 
and Belladonna are useful and act satisfactorily. A hypo- 
dermic of Morphia (}i to y 2 grain combined with -^ or 
a grain of Atropia), according to the intensity of the pain 
and repeated as required, may be administered. When 
possible, it should always be preceded by a large stimulating 
rectal enema to favor the progress of the foreign mass. 
The patient usually quiets down, becomes easy or falls 
asleep, to awake free from pain, with, possibly, only a little 
soreness of the parts. In some, however, the use of Morphia 
is followed by many unpleasant symptoms, especially in the 
gouty; it may be the direct cause of instituting an attack 
of gout which may be more painful than the colic itself. 
In these and many other cases satisfactory results have been 
obtained by the administration of the indicated remedy ; 
relief is not immediate, but the attack of gout is avoided. 
The passage of a full-sized steel sound into the bladder has 
been recommended and used with satisfactory results ; its 
action is probably reflex, causing the ureters to dilate and 
allowing the urine behind to push the obstruction into 
the bladder. 



CHAPTER XV. 
RENAL INJURIES AND FISTULA. 

TRAUMATISM OF THE KIDNEY. 

Etiology. — Injuries to the kidney may be caused by 
puncture, gun-shot wounds, or external violence. Incised 
or gun-shot wounds may involve adjacent organs, and 
at the same time foreign bodies may be carried into the 
deeper tissues and produce other complications. Injuries 
from external violence may happen without breaking of 
the skin, as from blows, falls or the squeezing of the parts 
between heavy bodies. When the capsule of the kidney 
is not ruptured haemorrhage is slight ; when the kidney 
is lacerated the line of rupture is usually transverse, rarely 
longitudinal. When occurring with other injuries, it may 
be overlooked. 

Clinical History. — As a rule but one kidney is injured, 
and, as its fellow is supposed to be healthy and able to do 
the work of both, traumatism has an advantage over dis- 
eased conditions. Collapse and shock usually follow im- 
mediately together, with pain referred to the renal 
region, accompanied by local haemorrhage and hsema- 
turia. When the kidney and its appendages are wounded, 
nature often, during the state of collapse, plugs the 
renal artery, the secretion of urea stops and only a 
watery fluid is exuded with the blood, and, consequently, 
destruction of tissue from decomposing urine is rare. 
When a kidney is ruptured, swelling occurs in the region 
of the kidney, with an accompanying rise of temperature 



RENAL FISTULA. 171 

to 103 or 105 F. In some cases the traumatism is so 
slight that pain in the renal region and a slight hsematuria 
may constitute the entire clinical history. 

Treatment. — The administration of Arnica, Aconite, 
Belladonna, or Veratrum vir., as indicated, with rest, hot 
formentations and stupes in the lighter cases, is all sufficient. 
If there is an incised or gun-shot wound, with evidence of 
peritoneal involvement, a laparotomy should be made, and 
the kidney removed if necessary. If the injury has not in- 
volved the peritoneal cavity, the calibre of the lumbar 
wound should be increased to allow of careful examination, 
a catheter inserted for drainage, and the wound packed 
with Iodoform gauze to arrest haemorrhage. When the 
kidney has been fractured, if the peritoneum is not 
involved, it should be examined through a lumbar explora- 
tory incision, the parts likely to slough should be removed , 
the wound packed and proper drainage provided. In 
many cases, on account of liability to infection and the 
possible formation of abscesses and renal sinuses, which 
are so unsatisfactory to treat, removal of the kidney is 
advisable. If the pelvis of the kidney is ruptured, its 
edges must, if possible, be sutured. It must also be 
remembered that in this condition, for some unknown 
reason, anuria sometimes develops, even when the opposite 
kidney is healthy. The possibility of the existence of but 
one kidney should also be considered. If the injured kid- 
ney is dislocated and can be saved, it should always be 
sutured to the posterior abdominal wall. 

RENAL FISTULA. 

Etiology. — They may be caused by or follow trauma- 
tism, surgical injuries of the kidney, or result from the rup- 
ture of a pyonephrotic, pyelonephrotic or perinephrotic 
abscess. They are seldom of surgical origin, except when 
the pelvis of the kidney is directly opened, unless necrotic 



172 UROPOIETIC DISEASES. 

or infected tissues have been involved in the operation. 
They are often due to the presence of a foreign body, such 
as a calculus or piece of drainage tube, excessive and con- 
tinued suppuration, incomplete drainage, and the con- 
tinued escape of urine through the opening. 

Clinical History. — Renal fistulse have received special 
names according to their point of opening. Reno-cutane- 
ous fistulse have thickened and indurated walls, are 
usually quite direct, and open as a rule in the lumbar or 
inguinal region. An erythematous patch of integument 
surrounds the ulcerated opening, from which a quantity of 
pus and urine escapes. Reno-intestinal fistulse gener- 
ally open into the colon, and are characterized by vomiting 
with purging of pus and urine. Reno-gastric fistulae are 
very rare. Three cases have been reported where renal 
calculi entered the stomach by a reno-gastric fistula and 
were expelled by the mouth. Reno-bronchial fistulae have 
also occurred. 

Treatment. — Free, direct drainage, when possible, is al- 
ways indicated. If the ureter is or can be made pervious, 
the usual surgical methods of packing the fistulous tract 
after curetting will result in granulation and closure from 
the bottom, or the walls of the fistulous tract can be re- 
moved and the wound closed with cat-gut sutures. If the 
ureter cannot be rendered pervious, and the opposite kid- 
ney is normal, a nephrectomy will be indicated. 



CHAPTER XVI. 

SUPPURATIVE NEPHRITIS. 

Etiology. — Suppurative nephritis may result from ex- 
ternal violence or originate within the kidney from irrita- 
tion of a calculus in its substance, the breaking down of 
a tubercular mass, by extension of inflammation from 
neighboring organs, surgical operations upon or in the 
region of the kidney or genito-urinary tract ; exposure to 
wet and cold, infarction, embolism from malignant 
endocarditis, pyaemia, an ascending infection from the 
bladder, etc. Von Wunschheim says: "First, pyelone- 
phritis is the result, in the great majority of cases, of in- 
fection by the bacterium coli commune ; in a fewer num- 
ber of cases through the proteus, or the more ordinary 
forms of suppurative cocci. Second, a certain number of 
cases in which the ordinary pyogenic microbes are the 
cause of the irritation and consecutive pyaemia results. 
Third, pyelonephritis resulting from irritation of staphyl- 
ococci and streptococci is not to be differentiated from 
other forms alone by the pyaemia present, but also, micro- 
copically, by the marked necrosis of tissue and the absence 
of increased inflammatory tissue formation, which is pro- 
duced by the bacilli coli commune. Fourth, it is not 
probable that the typical ascending pyelonephritis can be 
produced by the passage of micro-organisms from the 
hladder through the circulation." 

Pathological Anatomy. — Suppurative inflammation of 
the kidney may occur idiopathically or it may be due to 
various causes. 



174 UROPOIETIC DISEASES. 

When idiopathic, the kidney from some unknown 
cause is the seat of one or more abscesses. The abscess (or 
abscesses) may involve the whole of the kidney structure ; 
it may be completely enclosed in a dense fibrous capsule, 
probably the thickened capsule of the kidney, or it may be 
connected by one or more sinuses with the surrounding 
soft parts. There may be an abscess of considerable size 
involving a part of the kidney, and a number of smaller 
ones, varying in size from a pin-head to a pea. As a rule, 
but one kidney is involved. 

When of traumatic origin it may be due to perforating 
wounds which have involved the kidney tissue or to 
violent blows in the lumbar region. The inflammation 
may be diffuse and the whole kidney converted into a. 
purulent mass, or one or more circumscribed abscesses may 
be formed. 

Suppurative pyelonephritis generally affects both kid- 
neys. The mucous membrane of the pelvis is inflamed 
and covered with fibrin and pus, and throughout the kid- 
ney are numerous small abscesses, some so minute as to be 
seen only by the microscope. In addition, there is a 
diffuse suppurative inflammation. The tubes are filled 
with pus and blood. The stroma is infiltrated with pus 
cells. The mucous membrane of the ureters is often thick- 
ened and covered with fibrin and pus. In many instances 
the inflammatory process can be traced to the bladder, thus 
determining the source of infection. 

If there is a pre-existing malignant endocarditis or 
pyaemia, small infectious emboli may be deposited in the 
kidney structure with the formation of abscesses. The 
whole kidney is enlarged and congested. The cut surface 
is studded with small reddish areas having whitish centres, 
which, when examined microscopically, are found to be 
zones of congestion surrounding purulent foci and the 
beginning of a diffuse inflammation which results in swell- 



SUPPURATIVE NEPHRITIS. 175 

ing and death of the renal epithelium. Cocci may some- 
times be found in the abscess cavities. 

Clinical History. — One or both kidneys may be in- 
volved. The condition, however, is usually uni-lateral and 
distinct from other renal diseases. It may complicate 
Bright's and other lesions of the kidney. There is some 
swelling or fullness of the loin on the affected side, with 
tenderness on deep pressure. As the kidney is so deeply 
seated fluctuation is difficult to obtain, nor is it well to 
wait for its appearance before resorting to surgical means. 
The temperature, which is remittent in character, often 
reaches 103 F., and in many cases gives sufficient 
evidence of the presence of pus to warrant a nephrotomy 
long before the conclusive physical signs appear, and if pus 
is not discovered no harm has been done. When pus is 
present it may be clear and creamy or thin, ichorous 
and very offensive. 

When the abscesses are small they may become encap- 
sulated, rupture into the pelvis of the kidney when blood 
and pus will be voided with the urine, or the pus may 
burrow into the neighboring tissues and ultimately find 
its way to the surface or into the peritoneal, pericardial or 
pleural cavity, and cause death by shock. 

Symptoms are rarely perceived during life in infarction 
caused by emboli from endocarditis, and even when the 
endocarditis is of a malignant or septic type they are 
masked by the general condition. When suppurative 
nephritis is the result of mechanical injury or surgical in- 
terference, the violent and repeated chill, fever and sweat, 
vomiting and other digestive disturbances, as well as pain, 
swelling, etc., in the region of the injured or diseased 
kidney, will be marked, and blood and pus may appear in 
the urine. Recovery may take place, or the patient may 
pass into a typhoid state and die. 

When of the ascending variety from cystitis following 



176 UROPOIETIC DISEASES. 

gonorrhoea, stone in the bladder, or when it follows oper- 
ation on the genito-urinary tract, there will be chills, ir- 
regular rise in temperature and profuse sweat with a rap- 
idly developing typhoid state. The urine, which is 
diminished or suppressed, will contain blood and pus. 

When the result of an enlarged prostate, or renal calculi, 
the patient is generally over fifty years of age. The onset 
of the disease may or may not be preceded by urinary 
symptoms. Chill and fever are usually present to a 
moderate degree, though they may be absent. The first 
symptom may be a decrease in the quantity of urine voided, 
with hsematuria. Manifestations of sub-acute septicaemia 
soon appear with anxiety, feeble pulse, etc., followed, in a 
short time, by death. 

When of bacterial origin, the condition generally termi- 
nates fatally. 

Treatment. — Veratrum vir., Arnica, Aconite or Bella- 
donna in the beginning is often of decided benefit, and 
will frequently abort the attack ; later, Heparsulph., Hekla 
lava, Silicea, Sulpho-carbolate of soda, etc., will be neces- 
sary. Special attention should be given to the diet, 
which must be easily assimilated and nutritious, di- 
rected towards building up the patient and to repairing 
the waste going on in the system. Liquid peptonoids, 
somatose, kumyss, matzoon, Hudson's food, malted milk, 
beef peptonoids, clam broth, etc., should, therefore, be 
recommended. Hot fomentations and full hot baths are 
very comforting and beneficial. When pus forms it must 
be evacuated ; removal of the diseased kidney may some- 
times be necessary. Dr. Weir, Medical Record, Sept. 15, 
1895, reports a case of surgical kidney of the right side 
cured by removal of the diseased organ, followed by treat- 
ment of the chronic urethral trouble, which was the excit- 
ing cause. When the condition of the patient warrants it, 
Dr. Weir advises an exploratory incision and the opening 



SUPPURATIVE NEPHRITIS. 177 

up of the capsules of one or both kidneys, in order to re- 
lieve the tension, and when one kidney only is involved, to 
remove it, if indicated. 



12 



CHAPTER XVII. 

DISEASES OF THE KIDNEY. 

ACUTE CONGESTION OF THE KIDNEYS. 

Etiology. — Acute congestion of the kidney is frequently 
produced by excessive and unusual exertion, as in baseball 
and football games, bicycling, mental excitement, and from 
cold baths or exposure. It may be the result of severe 
bodily injury, or surgical operations, especially those con- 
nected with the genito-urinary system. It is frequently 
caused by irritant drugs, i. e., Cantharides, Turpentine, 
Ether, Chloroform, etc., when ingested, inhaled as vapors, 
following their local applications to various parts of the 
body or during their elimination. 

Pathological Anatomy. — There is no change in the 
structure of the kidney. The blood vessels are more or 
less engorged, depending upon the severity of the attack. 
There may be an exudation of serum and leucocytes, or 
diapedesis of red blood cells into the tubes and glomeruli. 
Upon recovery the kidneys return to their normal con- 
dition. 

Clinical History. — In itself it is of importance only 
as accompanying some other condition. It is usually 
transitory and soon subsides. It may, however, develop 
into an acute nephritis, and in some cases may, espe- 
cially after surgical operations, particularly those of the 
genito-urinary tract, prove rapidly fatal, death occurring 
in one or two days, others pass into a typhoid condition, 
and after giving marked indications of ursemic poisoning 
terminate in recovery. 



ACUTE CONGESTION OF THE KIDNEYS. 179 

When the cause has been the administration of Can- 
tharides, Turpentine, etc., the general symptoms will 
vary with the quantity of the drug introduced into the 
system. There will be some rise in temperature, nausea, 
vomiting and diarrhoea, pain in the loins, frequently ex- 
tending across the abdomen, with moderate stupor and 
delirium. When from over-exercise the general symptoms, 
except the change in the urine, frequently pass unnoticed. 
This fact is well demonstrated by cases reported by Dr. 
Andrew Macfarland in the Medical Record of Dec. 
22, 1894. He carefully examined the urine of the mem- 
bers of a football team before and after a game, and 
though in each case there was no clinical evidence of dis- 
ease, he found albumen, casts aud epithelia in the urine, 
which entirely disappeared, and the urine, in from a few 
hours to a few days, returned to a normal state. 

The clinical history, therefore, may be said to vary 
greatly. The urine is albuminous and smoky ; it may 
contain red blood corpuscles and tube-casts of various 
kinds, especially hyalin. The urine of the football 
players referred to above contained large and small granu- 
lar, blood and epithelial casts. 

Prognosis depends upon the cause. If due to excessive 
bodily exercise, recovery almost always occurs, unless the 
cause is too often repeated, when it may be the beginning 
of a serious kidney lesion. If from poison, it will depend 
upon the quanty taken in the system. If the result of a 
surgical operation, it will depend upon the severity of the 
original cause, though some surgical cases die from conges- 
tion of the kidneys, even when the operation has been 
comparatively trivial. 

Treatment. — If the congestion is from over-exertion, 
Arnica, Sandalwood or Aconite ; from exposure, Aconite, 
Dulcamara, Belladonna or Rhus tox ; from surgical 
operations, shock or mechanical injuries, Veratrum vir., 



180 UROPOIETIC DISEASES. 

Aconite, Arnica, or Belladonna ; when associated with 
gastric or hepatic disturbances, pain in the back, etc., Mer- 
curius corr., Cantharides, or Terebinth. For general symp- 
tomology see chapter on renal therapeutics. 

Rest in bed is of great importance. Baths at a tempera- 
ture of ioo° F. Hot packs over the loins and hot foot 
baths, with an absolute milk or fluid diet and an abund- 
ance of pure (not hard) water, preferably Poland or Hygeia, 
are always indicated. 

Acute congestion of the kidney, resulting from surgical 
operations, is very liable to prove rapidly fatal and the best 
directed treatment will often fail. If the lesion has been 
caused by poison, an antidote should be administered and 
the poison eliminated as soon as possible from the stomach 
and system. When from Cantharides, two to four grains 
of Camphor should be given every two to four hours, as 
an antidote, whether the drug has been introduced by the 
mouth or in the form of a blister. 

CHRONIC CONGESTION OF THE KIDNEYS. 

Etiology. — This condition is caused by venous stasis 
in the renal circulation due to weakness in the heart- 
power, from chronic endocarditis, myocarditis or dilatation, 
aneurism of the arch of the aorta, pulmonary emphysema 
or carnification ; also by the long continued presence of 
pathological fluids in the pleural sac. It is a frequent 
concomitant of chronic cardiac disease, but it appears only 
when there has been sufficient loss of the heart tone or 
power to allow the venous blood to accumulate abnormally 
in the veins of the kidneys. 

Pathological Anatomy. — The kidneys may be large 
or normal in size. They are proportionately heavy and 
firm in consistency. The surfaces are smooth, the cap- 
sules non-adherent. They are dark in color, but there is 
a marked contrast between the pyramids and cortex, the 



CHRONIC CONGESTION OF THE KIDNEYS. 181 

latter being somewhat paler and of a bluish-gray tint. 
The cells covering the capillary tufts are swollen ; some oi 
the cells lining the glomeruli are swollen, and opaque, 
others are normal. In the tubes of the cortex the epithe- 
lium may be swollen or flattened. The swollen cells are 
granular. The lumen of the tubes may contain fibrin, 
leucocytes and red blood cells. The stroma is unaltered. 

Clinical History. — Chronic congestion of the kidney 
may be suspected when there is a history of marked pul- 
monary emphysema, or carnification produced by chronic 
pleuritic adhesions, or from any weakness of the heart 
power. The clinical manifestations will vary greatly with 
the original cause, the concomitant pathological conditions 
and other renal lesions, i. e., chronic degeneration, inter- 
stitial or parenchymatous nephritis. 

The urine is scanty, dark in color, of high specific 
gravity, and, on standing, deposits large quantities of 
urates and uric acid. Albumen is sometimes present in 
small quantities, together with a few hyalin casts and red 
blood corpuscles. Dropsical conditions are frequently 
present, the oedema being confined to the lower extremi- 
ties, while the upper extremities and face escape, thus as- 
suming the character of a cardiac dropsy. There is a 
diminished secretion of urine, accompanied by gradual 
loss of strength and flesh, nausea, vomiting, headache, 
delirium, coma, and possibly convulsions. In other cases 
a typhoid state may develop. 

Treatment. — Arnica has been given with satisfactory 
results when there was general dropsy with a bruised feel- 
ing of the body. Convallaria when from cardiac dilata- 
tion and hypertrophy ; heart's action rapid and irregular, 
with general anasarca and lame feeling in the back, ag- 
gravated by lying down. Digitalis when there are suffo- 
cating spells, sinking, faint feeling at the pit of the 
stomach, feels as if about to faint, pulse feeble and slow ; 



182 UROPOIETIC DISEASES. 

renal congestion, due to enfeebled muscular power of left 
ventricle. Phosphorus in renal congestion, due to loss 
of muscular power of right ventricle ; weak, empty feeling 
in whole abdomen. If the cause can be removed or 
ameliorated, much comfort and relief can be given the 
patient. When chronic congestion of the kidney is due 
to cardiac disease, physiological treatment may be indi- 
cated. An over-acting heart, or excessive action, due to 
contraction of the arterioles, will require Nitro-glycerine. 
If there is simple over-action Aconite, Belladonna or 
Veratrum viride may act satisfactorily. If there is want 
of tone or weakness, Digitalis, Strychnine, Caffein, or 
Strophanthus. Delafield advises small doses of Codeia or 
Morphia in the later stages of chronic congestion of the 
kidneys from aortic and mitral stenosis or myocarditis, 
with disease of the coronary arteries. Hot air baths may 
be required, and sometimes prove very beneficial. Rest 
in bed is frequently very important, and good nourish- 
ing food, especially animal diet, should be recommended. 

ACUTE NEPHRITIS. 

Etiology. — Acute nephritis occurs most frequently in 
the aged, and is more prevalent in damp climates, the 
most common causes being exposure to cold and damp, 
mechanical injuries or irritation from calculi. 

Clinical History. — One kidney alone is involved. The 
disease begins with a chill, followed by high fever, with 
dull pains over the affected organ, aggravated by motion 
and pressure. The pain may radiate to the umbilicus, 
down the thigh, and along the course of the anterior 
crural- nerve ; the testicle on the side involved is usually 
retracted. Nausea and vomiting accompany the early 
symptoms, diarrhoea and tenesmus are not infrequent. 
The urine is scanty, high-colored, of increased specific 
gravity, and may contain blood and some albumen ; 
micturition is frequent. 




(MAGNIFIED 450 DIAMETERS.) 
FIG. I. 

ACUTE DEGENERATION OF THE KIDNEY. 

a. Degenerated epithelium, b. Lumen of tubule obliterated by swollen 

and necrotic epithelium. 




( MAGNIl 



CHRONIC CONGES 
a. Capillary tuft, showing a swelling 

b. Swollen epithelium of tubules. 
epithelium, detached 



riON OF THE KIDNEY. 

Of the epithelium and dilated capillaries. 



ACUTE DEGENERATION OF THE KIDNEY. 183 

Prognosis is favorable. Recovery usually takes place 
in from one to three weeks, although suppuration may 
result. 

Treatment. — As directed for acute parenchymatous 
nephritis. 

ACUTE DEGENERATION OF THE KIDNEY. 

Etiology. — Conditions of the blood dependent upon 
acute and infectious diseases often produce acute renal de- 
generation. It is also caused by the presence in the sys- 
tem of certain mineral poisons, as Arsenic or Phosphorus. 
The Bi-chloride of mercury has frequently produced it 
when used as an antiseptic dressing or douche, and 
Weilander, in Univ. Med. Journal, August, 1894, from 
Hygiea, 1894, reports that symptoms of degeneration of 
the kidney were observed in ninety-nine cases of syphilis 
while under mercurial treatment, which disappeared when 
drug was eliminated from the system. The degree of 
degeneration or death of the epithelium and the quan- 
tity of exudate from the blood vessels varies with the 
amount of the poison introduced into the system. As a 
concomitant of infectious diseases, the degree of acute 
degeneration varies with different epidemics. For reasons 
not at present known, the pathological changes, whether 
caused by an acute infectious disease or a mineral poison, 
are identical. 

Pathological Anatomy. — The kidneys are increased in 
size, surfaces smooth, capsules non-adherent, and the corti- 
cal portion thickened and pale. The degenerative 
changes take place in the parenchyma of the organ, 
and more markedly in the convoluted tubules. The 
epithelium lining the glomeruli and tubules, and that 
covering the capillary tufts of the glomeruli, is swollen 
and opaque ; sometimes the swelling is so great as to com- 
pletely fill up the lumen of a tubule. The swollen cells 



184 UROPOIETTC DISEASES. 

may be infiltrated with granular fatty substance ; some of 
the cells become detached from the wall of the tubule, or a 
part of the cell may tear ofl and drift away as granular 
debris. 

In the lumen of the convoluted tubules may be seen 
hyalin material, and in the straight tubules detached 
epithelium and hyalin casts. 

Clinical History. — This is important only as the con- 
dition is an accompaniment of the acute infectious diseases 
— measles, scarlet fever, typhoid, yellow fever and pneu- 
monia — or in cases of poisoning by Mercury, Arsenic, 
Phosphorus, etc. It is not accompanied by dropsy or 
arterial tension. It is usually transitory in nature, and as 
the condition causing it is removed or disappears the parts 
return to their normal state. When following a severe 
case of mineral poisoning, or accompaning acute infectious 
diseases, as yellow fever, etc., delirium, convulsions, coma, 
and death sometimes occur, though it is often difficult to 
say whether death is due to the kidney lesion or to the 
action of the original cause in other organs of the body. 
Micturition is increased in frequency, and the urine is 
usually diminished in quantity or suppressed. It has a 
smoky appearance, contains albumen, blood and casts ; the 
specific gravity is normal, or slightly increased. It should 
be always remembered that in the acute infectious diseases, 
acute degeneration of the kidney appears especially in the 
early stages, while acute parenchymatous nephritis occurs 
late in the progress of the case, and its prognosis is far 
more grave. 

Treatment. — The remedies most frequently required are 
Belladonna, Cicuta, Arsenicum, Apis mel., Terebinth and 
Rhus tox. For special indications see chapter on renal 
therapeutics. 

If caused by a mineral poison, it should be eliminated at 
once and an antidote administered. If from an infectious 



CHRONIC DEGENERATION OF THE KIDNEY. 185 

disease, the treatment directed to the existing cause will 
generally suffice. 

CHRONIC DEGENERATION OF THE KIDNEY. 

Etiology. — The principal cause of chronic degeneration 
of the kidney is obstruction to the circulation from cardiac 
or pulmonary disease. It occurs sometimes without 
apparent reason. It may be due to the cachexia which 
accompanies catarrhal phthisis, pulmonary tuberculosis, 
cancer, etc. It seems to be a grade beyond a chronic con- 
gestion of the kidney, and is characterized by degeneration 
of the epithelia lining the urinary tubules. 

Pathological Anatomy. — The kidneys are enlarged and 
two or three times heavier than normal. Their surfaces 
are smooth. The markings are very distinct. There is a 
decided contrast between the cortical and pyramidal por- 
tions — the former being pale and thickened, the latter 
hyperaemic and dark. The epithelium lining the con- 
voluted tubes is swollen and granular ; the cells covering 
the capillary tufts of the glomeruli are swollen and the 
capillaries themselves are dilated. The veins of the pyra- 
mids are engorged. Sometimes the kidneys are not 
enlarged and show no change in the gross appearance 
other than congestion of the pyramids. 

Clinical History. — Chronic degeneration of the kidneys 
is very often overlooked. The .urine may be normal, 
or occasionally contain a small quantity of albumen 
and a few casts; this is especially true in cases due to 
grave chronic constitutional disease or some unknown 
cause. When the condition accompanies chronic heart 
lesions, the urine may vary in quantity, and often be- 
comes scanty or suppressed. The specific gravity is about 
normal; the percentage of urea is scarcely affected. 
Chronic degeneration of the kidneys does not of itself 
cause dropsical symptoms, disarrange the heart's action, 



186 UROPOIETIC DISEASES. 

or produce uraemia. There is an interference with the 
power of assimilation and, consequently, progressive weak- 
ness and emaciation, which may finally become so marked 
as to cause death from asthenia. 

Treatment. — The remedies most frequently indicated 
are Phosphorus, Arsenicum, Rhus tox., etc. For symp- 
tomatology see chapter on renal therapeutics. The diet 
should be liberal and easy of digestion and assimilation. 
The general hygiene and regulation of the habits of the 
patient must receive proper attention and the original 
cause be removed or ameliorated. 

BRIGHT'S DISEASE. 

This generic term includes a large class of acute and 
chronic lesions of the kidneys. The presence of albumen 
in the urine was for many years considered conclusive 
evidence of nephritis. Senator and his followers have 
been equally positive that the urine is always a weakly 
albuminous fluid; in other words, that there is often a 
physiological albuminuria. It is quite probable that both 
views are, in a great measure, correct. If the search for 
albumen, serum albumen and serum globulin is confined 
to heat, cold nitric acid, or the potassium ferrocyanide 
test, and evidence of albumen is found, a nephritic condi- 
tion can be diagnosed, but when it is possible to demon- 
strate it only by the Millard and similar delicate tests, the 
probabilities are that the substance producing the reaction 
is mucin or nucleo-albumen and unimportant as far as the 
diagnosis of a nephritic condition is concerned unless con- 
firmed by proper microscopic investigations. If the value 
of these tests is not thoroughly understood, they often 
lead to a false prognosis and cause unnecessary anxiety. 

M. Cloetta, of the University of Zurich {Arch, fur Patho- 
logie und Pharmokologie, 42, 1899, p. 452), contributes a 
series of clinical observations, experiments and pathologi- 



bright's disease. 187 

cal studies on the origin of serum albumen, serum globu- 
lin and nucleo-albumen. 

The methods of experimentation employed were various, 
but most of them depended on the relationship of the 
bodies found in the blood and in the urine, following some 
definite method of kidney irritation. Experiments mak- 
ing use of osmolytic phenomena were also freely employed. 
These seemed to show that the character of the transfused 
albumen depended in large part on the thickness and 
permeability of the osmotic membrane, and thus pointed 
directly to the suggestion that in the kidneys themselves, 
the thinner the epithelial layers, the more closely the 
transudate resembles the composition of the incoming fluid, 
t. <?., the blood and certain of its albumen constituents. The 
thicker membranes render the passage of globulins more 
difficult. When this result is borne in mind with the 
clinical experience, that in acute nephritis the serum 
globulin is quite appreciable, and that on the other hand 
the serum albumen quotient is much higher in chronic 
contracted kidney, and that as recovery gradually takes 
place in acute nephritis the serum albumen increases, it 
may be seen that some correlation may be made between 
clinical and experimental results. 

With reference to the presence of nucleo-albumen the 
author is of the opinion that it comes not so much from 
the blood-current as from the renal epithelium itself. 
Thus in the acute degenerative types of nephritis it is 
nearly always present and originates in the degenerated 
cells of the tubules ; in chronic indurative cases it is present 
in small quantities only. In cases of eclampsia it is 
absent, whereas in the nephritis of the acute infectious 
diseases nucleo-albumen is found in large quantities. It 
thus serves as an index of the amount of cellular degen- 
eration in the renal structures. 

The occasional presence of albumen in the urine, pro- 



188 UROPOIETIC DISEASES. 

vided the normal urinary 7 constituents remain unchanged 
in quantity and quality, need as a rule excite no immediate 
alarm. Albuminuria may be due to some trivial localized 
lesion of the kidney which may remain stationary or 
slowly develop into a condition menacing life. That this 
is true, it is only necessary to enumerate the many patients 
who live for years with albumen in the urine and die 
from other causes ; also, how infrequently at the autopsy 
both kidneys are found healthy, and finally the Harris' 
method of urinary segregation often demonstrates that 
one kidney is seemingly secreting normal urine, while 
'the other gives decided evidence of disease. Further- 
more, from the prognostician's position, it must be re- 
membered that the kidneys are so constructed that a 
large part of their glandular tissue may be destroyed 
before any general effect is produced upon the system, the 
first evidence of disease being the presence of albumen in 
the urine. In chronic cases this generally happens long 
before the emunctory process is deranged, with accom- 
panying diminution in the toxicity of the urine and corre- 
sponding increase of toxic or poisonous material in the 
blood, with its long train of symptoms. 

At one time, the albumen voided with the urine was 
believed to drain the system, thin the blood and allow 
dropsical conditions to occur, but the amount of albumen 
lost even in the most severe acute or chronic cases rarely 
exceeds nine or ten grains a day. If the digestive apparatus 
is in good condition, it is of little moment as compared to 
the drain upon the system during lactation, etc. Albu- 
minuria, except as a diagnostic symptom, has been given too 
much dignity in the clinical history of Bright's disease. 
The exudation of albumen is only a symptom indicating a 
damaged condition of the kidney, produced by the presence 
of some toxine in the blood, the product of some known 
or unknown micro-organism. In time this toxine not 



BRIGHT 'S DISEASE. 189 

only damages the tufts of blood vessels in the kidneys, etc., 
but also attacks the endothelial lining of the minute 
vessels of the skin and other tissues, and under certain con- 
ditions allows the serum of the blood to transfuse into the 
serous cavities or tissues and produce the different types of 
cedema or dropsy. 

In a given case of Bright's disease, when albumen is 
found in the urine, the degree of kidney lesion could be 
interrogated by an analysis of the blood to determine the 
amount of retained urea ; from the relative percentage of 
urea present, the deduction can be computed. 

If ursemic symptoms are not particularly prominent, the 
methylene blue test may be employed. This test depends 
upon the fact that if methylene blue is subcutaneously 
injected into the muscle of a healthy adult it will appear in 
the urine in from ten to thirty minutes and be entirely 
removed in fifteen to forty-eight hours, thirty-six hours 
being the average. When this elimination is delayed to 
two to seven or more days, in that proportion can the per- 
meability of the kidneys be judged. When administered 
by the mouth it should disappear more rapidly, usually in 
eighteen to forty hours. 

The relationship of any special bacillus to nephritis has 
not as yet been positively demonstrated, though both 
Mannaberg and Bugel have separated a distinct and un- 
named micro-organism in nephritis which disappeared as 
recovery occured. Whether nephritis in general has a 
special germ origin, or whether there is a special micro- 
organism for each variety, is yet to be demonstrated, but 
from experiments and examinations already made it is 
believed that it may be safely stated that Bright's disease 
is due to a poisoning or irritation of the kidney tissues by 
ptomaines, special toxines, or other poisons present in the 
blood, as seems well exemplified in malaria, scarlet fever, 
diphtheria, etc. The long-continued presence in the 



190 UROPOIETIC DISEASES. 

blood stream of the toxines of the golden staphylococcus 
has produced amyloid changes. 

Nichollis is of the opinion that chronic nephritis, as a 
rule, is caused by the bacilli coli communi, though other 
germs may produce this lesion of the kidney, the point of 
invasion being through the intestinal tract ; the liver and 
mesenteric glands when in normal physiological func- 
tional condition act as barriers to their entrance into the 
circulation, the other germs have various means or points 
of entrance. Although the endothelial cells lining the 
capillaries and secreting tubules of the kidneys possess the 
power of eliminating micro-organisms, if, for any reason, 
they are present in excess for a continued length of time, 
chronic nephritis may result. Cantharides, Bichloride of 
mercury, in those who are susceptible, may produce lesions 
of the kidneys by their irritative presence. 

For convenience of description, Bright's disease will be 
classified as acute and chronic. The acute will be fur- 
ther divided into acute exudative and productive varieties, 
and the chronic into chronic parenchymatous, interstitial 
and amyloid nephritis. 

ACUTE PARENCHYMATOUS NEPHRITIS. 

Acute Bright's, Acute Croupous Nephritis, Post Scarla- 
tinal Nephritis, Tubal Nephritis, etc. 

Millard describes this condition as a nephritis character- 
ized by exudation into and infiltration of the connective 
tissue, with secondary changes in the epithelium, the 
whole leading to the formation of casts and being invari- 
ably accompanied by albuminous urine. Delafield divides 
this condition into the acute exudative and acute pro- 
ductive nephritis. Acute exudative nephritis he describes 
as an inflammation of the kidneys characterized by con- 
gestion, exudation of the blood plasma, emigration of the 
white blood-cells, diapedesis of the red blood-cells, to 



ACUTE PARENCHYMATOUS NEPHRITIS. 191 

which may be added changes in the renal epithelium and 
in the glomeruli, and acute productive nephritis as an 
acute inflammation of the kidneys, characterized by exu- 
dation from the blood-vessels, a growth of new connective 
tissue in the stroma and changes in the epithelium and 
glomeruli. The pathological changes in these two forms 
are easily recognized by the postmortem, and they can 
usually be differentiated diagnostically antemortem. As 
their clinical histories are similar, they will be classed 
under the general head of acute parenchymatous nephritis. 
Etiology. — Acute parenchymatous nephritis is most 
frequent in childhood; it is rare in those past forty 
years of age. When nephritis occurs before the twelfth 
year, it is usually of the exudative variety; after that 
period the majority of the cases are sub-acute in character 
and of the productive form. This is readily explained 
when the exciting causes are considered. Acute paren- 
chymatous nephritis is often due to exposure to 
draughts, especially after bathing or overheating the 
body, colds, from getting wet, improper or unseason- 
able clothing, etc. In childhood, the most frequent 
cause is the presence in the blood of the bacteria of 
some of the infectious diseases or their ptomaines, which, 
while passing through the kidneys in the process of ex- 
cretion, produce at first irritation of the parenchyma and 
ultimately inflammation, which, if of the exudative variety, 
will be transient in nature, but if productive will fre- 
quently result in chronic lesions. The disease, therefore, 
frequently happens as a complication or sequela of measles, 
scarlet fever, small-pox, typhus, typhoid, cerebro-spinal 
meningitis, influenza, parotitis, catarrhal tonsillitis, diph- 
theria, pneumonia, erysipelas, etc. The experiments of 
Vissman (Med. Record, Sept. 14, 1895) demonstrate that 
diphtheritic antitoxin is a common excitant of acute 
parenchymatous nephritis. Its occurrence in the diseases 



192 UROPOIETIC DISEASES. 

mentioned varies greatly in different epidemics, and it has 
been noticed that it bears no special relation to the sever- 
ity of the original infectious disease. It is not infre- 
quently a concomitant of acute articular rheumatism. 
Extensive burns of the body have been known to produce 
it, and it so often follows constitutional cutaneous lesions 
that they also may be considered as exciting causes. It 
also appears as a sequela of septic inflammation, surgical 
and puerperal fevers, anthrax, etc. 

Malarial conditions in many cases undoubtedly induce 
this disease, and during an attack of intermittent or of 
bilious remittent fever, albumen and renal epithelia can 
almost always be found in the urine. It is generally be- 
lieved that the presence of the bile acids in the blood, 
which, when excreted by the kidneys, irritate and lead to 
inflammation of the renal tissue on the same principle as 
the well-known effect of Turpentine, Copaiba, Cubebs, 
Ginger, Arsenic, Corrosive sublimate, Potassium chlorate, 
Carbolic acid, Pyrogallic acid, or Squills. 

The nephritis from the last named irritants is usually of 
the exudative variety, transitory, and subsides on the 
removal of the poison from the system. The same would 
be true of the irritants developed in the malarial diseases, 
were it not for the fact that the attacks are usually fre- 
quently repeated, and the frequent recurrence may develop 
a productive, or ultimately a chronic nephritis. Some- 
times an acute parenchymatous nephritis will engraft 
itself without discoverable cause on any one of the more 
chronic forms of Bright's disease, although these appar- 
ently new invasions in chronic nephritis must be con- 
sidered only as exacerbations. 

Bacteria in the blood, independent of any of the known 
germ diseases, have been known to produce acute paren- 
chymatous nephritis by their presence during the process 
of elimination, the lesion developing rapidly and termi- 



PLATE III. 




\ 



— e 



^^ 3r *(£&&&* *■' 

(MAGNIFIED 450 DIAMETERS.) 

FIG. I. 

ACUTE EXUDATIVE NEPHRITIS. 

. Convoluted tubules, filled with the exudate of fibrin, red blood cells and leucocytes. 

b. Exudate in stroma. 




(MAGNIFIED 450 DIAMETERS. 1 ) 
FIG. 2. 

ACUTE EXUDATIVE NEPHRITIS. 
5. The epithelium covering- the capillary tuft is swollen and opaque. 



b. Convoluted tubules, filled with exudate." 
flattened epithelit 



Tubule 



rith 



ACUTE PARENCHYMATOUS NEPHRITIS. 193 

nating in uraemia and death. These bacteria are rod- 
shaped and resemble the micro-organisms found in the 
blood of those suffering from typhus. In the bacterial 
form of acute parenchymatous nephritis the bacteria after 
death are found not only in the kidneys, but also in the 
blood and urine. When these bacteria are cultivated, 
even to the fourth generation, and rabbits are inoculated 
with the culture, a similar lesion of the kidney is pro- 
duced. This bacterial origin of acute nephritis accounts 
for many cases which would otherwise be mysterious, 
though it should be remembered that the presence of bac- 
teria in the urine does not necessarily mean pathological 
changes in the tissues, for micro-organisms do appear in 
the urine when all the organs are in a healthy state, as 
after drinking impure water or eating old cheese. There 
is also a certain inherent condition of the blood, without 
bacteriological contamination, which will, in itself, act as 
an irritant and induce nephritic inflammation. 

Pathological Anatomy. — The acute exudative type of 
acute parenchymatous nephritis is described by Delafleld 
as acute exudative nephritis. There is no connective 
tissue change in the stroma. The kidney is increased in 
size. The cortex is thickened and pale. If there has been 
a considerable exudation of pus cells, it may be evident 
by whitish foci of the exudate in the cortex. The surfaces 
are smooth and the capsules non-adherent. The epi r 
thelium of the convoluted tubules may be flattened and 
the tubules dilated, or the epithelium may be swollen and 
necrotic and in some places detached from the walls. 
The tubules may be empty, or they may contain the 
detached epithelium, hyaline material and masses of 
debris, probably portions of the necrotic cells. If the exu- 
dation has been excessive, they contain fibrin, pus, and in 
some cases red blood-cells. The straight tubes, in addition 
to the exudate, may contain hyaline, granular and epi- 
13 



194 UROPOIETIC DISEASES. 

thelial casts. In the glomeruli the epithelium is swollen, 
sometimes so much that the cells resemble those lining 
the tubes, and contain the same exudate. The cells of the 
capillary tufts are swollen, and the normal aspect, which 
shows the convolutions of the capillaries, is changed to a 
more or less inordinate mass of swollen epithelium. Al- 
though there is no connective tissue change in this form 
of nephritis, there may be an exudation of serum, leuco- 
cytes and red blood-cells into the stroma. The inflamma- 
tory process, as a rule, is not diffused throughout the 
whole organ, but localized in foci of varying size, some 
portions of the kidney remaining apparently normal. If 
the patient recovers, the inflammatory product is absorbed 
and the kidney returns to its normal condition. 

In acute productive nephritis there is, in addition to the 
pathological lesions of the exudative type, a new growth 
of connective tissue and permanent changes in the 
glomeruli. In the more recent cases, the surfaces of the 
kidneys are smooth, but where the inflammatory process 
is more advanced they may be roughened and the capsules 
adherent. The cortex may be pale and thickened, or it 
may be mottled red and yellow. The color may, how- 
ever, be unchanged. The cortex is hypersemic and dark, 
and the pelvis is, as a rule, deeply congested. The growth 
of new connective tissue takes place in wedge-shaped por- 
tions of the kidney; corresponding to the territory sup- 
plied by an artery. These affected areas may be concrete 
and discernible, or two or more may merge together and 
the change will be more or less diffuse. 

The epithelium of the convoluted tubules may be 
flattened, or the cells may be swollen, necrotic and de- 
tached. The tubes themselves contain fibrin, pus, and 
some of the necrosed cells. As a rule, the tubules, where 
the cells are flattened, do not contain as much exudate as 
those where the lining cells are swollen and necrotic. In 



\ 



(MAGNIFIED 450 DIAMETERS.) 

ACUTE) PRODUCTIVE NEPHRITIS. 

a. Capillary tuft. b. Hyperplasia of cells lining glomerulus, c. Connective tissue growth 
in the stroma, d. Tubules, with necrotic epithelium. 



a . 






a, . 



- 



ACUTE PRODUCTIVE NEPHRITIS. 

a. Convoluted tubules, with necrosis of epithelium. /'. New connective tissue growth, 
c. Detached epithelium. 



ACUTE PARENCHYMATOUS NEPHRITIS. 195 

the portion of the kidney where there is connective 
tissue growth, some of the tubules may be atrophied. The 
straight tubes may contain hyaline, granular and epithelial 
casts. In some of the glomeruli there is only a marked 
hyperplasia of the capsule cells, sometimes to such an ex- 
tent as to severely encroach upon the capillary tuft. 
These proliferated cells undergo fibrous degeneration. 
The cells of the capillary tufts are swollen and opaque. 

Clinical History. — The severity of the attack varies 
from one so slight that it passes unnoticed, or is only acci- 
dentally discovered by urinary analysis, to one where the 
inflammation is so intense as to quickly overpower the 
system and in a short time produce death. The exudative 
variety is usually intense, although in some cases the pro- 
ductive variety is equally acute and cannot by the 
symptoms be differentiated from the exudative. Product- 
ive parenchymatous nephritis is usually sub-acute in char- 
acter. The acute parenchymatous nephritis accompany- 
ing scarlet fever, that which develops during an attack 
of diphtheria and during pregnancy, is usually of the 
productive variety, and the prognosis is consequently more 
grave, death frequently resulting. Some recover, as is the 
rule with the exudative variety, but more often complete 
convalescence does not take place, although at the time 
the patient may seem to be restored to health. At 
varing intervals recurrent attacks take place, until finally 
the condition passes into the chronic form. The exu- 
dative variety of acute parenchymatous nephritis usually 
develops during an attack of some one of the infectious 
diseases, especially scarlet fever and diphtheria ; it is fre- 
quent during pregnancy. It is sometimes fatal, but the 
majority of cases run a rapid course of one or two months 
and entirely recover. 

In most cases of acute parenchymatous nephritis the 
cardinal diagnostic points are well marked, and give a 



196 UROPOIETIC DISEASES. 

picture so clear that it cannot be easily misunderstood, i. e., 
scanty, high-colored urine, with increased specific gravity, 
containing an abundance of albumen, blood, epithelial 
casts, epithelia and blood corpuscles, rapidly developing 
dropsy, both general and local, nausea, vomiting, head- 
ache, muscular twitching, convulsions, pain in the back, 
possibly epistaxis, increased or diminished heart impulse, 
high arterial tension, etc. The disease may commence 
with a distinct chill, followed by fever, the temperature 
rarely rising above ioi° F. This is the rule when ne- 
phritis is the result of exposure to cold or dampness. When, 
however, it occurs in the course of, or follows some other 
morbid condition, the fever may be due largely to the 
original cause. Fever is sometimes absent. Pain of a 
dull, aching character, referred to the small of the back 
and extending down the course of the ureters, is a frequent 
symptom. When the disease has been caused by expos- 
ure, the pain is not so marked as in the other varieties, 
and is often absent. 

Nausea, vomiting and headache frequently announce 
the commencement of an acute nephritis, especially when 
the disease occurs as the consequence of scarlet fever or 
other infectious disease. The vomiting is sometimes per- 
sistent and troublesome, but fortunately quickly disap- 
pears. Anaemia develops early, producing the character- 
istic waxy appearance. Dropsy and scanty urine are 
usually among the earliest symptoms. The dropsical 
condition first appears under the eyelids, and rapidly 
extends over the body, involving not only the lower 
extremities and scrotum, but also the serous cavities. It 
may also lead to the more serious oedema of the lungs. 
These dropsical accumulations follow no special course of 
development, and, therefore, vary greatly; in some cases 
the anasarca is so slight as to be scarcely noticeable. The 
amount of dropsical effusion often bears no relation to the 



ACUTE PARENCHYMATOUS NEPHRITIS. 197 

intensity of the renal involvement. As convalescence is 
established, the dropsical effusion slowly disappears, though 
sometimes it does so rapidly, accompanied by watery 
stools and polyuria. The quantity of urine generally bears 
a special relation to the dropsical condition and the degree 
of nephritic inflammation. Micturition is increased in 
frequency, though there may be complete anuria. Many 
cases are recorded where suppression of the urine persisted 
for days and was followed by complete restoration to 
health. Opinion varies as to the cause of the anuria. The 
urine, however, is usually scanty, smoky, reddish or pink 
from the admixture of blood and contains an abundance 
of albumen. In some cases it may be a few days be- 
fore albumen can be clearly demonstrated ; it is always 
present at some time or other in the exudative variety, 
and when it once appears it persists until the case is 
cured or death takes place. It may disappear in the pro- 
ductive form of the disease, or become quiescent, to 
reappear when an exacerbation shows itself simulating a 
new invasion. The chlorides are absent, the phosphates 
diminished and uric acid and the pigments are increased. 
The actual quantity of urea is diminished, the specific 
gravity is high, and varies from 1025 to 1030. The reac- 
tion is always acid. The sediment is" usually abundant and 
contains blood, hyaline, and granular casts, red and white 
blood corpuscles, epithelia from the convoluted and straight 
tubules and the pelvis of the kidney, with crystals of 
uric acid, urates, oxalates, etc. As health is re-established 
the specific gravity is usually lowered, and may fall as 
low as 1010, with polyuria; this, however, soon dis- 
appears and is followed by the establishment of the normal 
urinary secretion. 

The pulse is hard, tense and increased in frequency. 
The tension of the arterial system is always marked, and, 
as a consequence, dilatation of the heart sometimes occurs 



198 UROPOIETIC DISEASES. 

rapidly — in from two to four days. Compensatory hyper- 
trophies are frequent, and may be distinguished by the 
physical signs during life. When compensatory hyper- 
trophy does not take place, the dilation often gives rise 
to dyspnoea, even when pulmonary oedema is absent, and 
sometimes produces sudden death. 

Ursemic symptoms and complications are ushered in by 
headache, stupor, jactitations, convulsions, etc., which may 
come on insidiously. This is especially true in ursemic 
dyspnoea, a condition from which the patient rarely 
recovers. The ursemic conditions may appear when the 
urine is copious and free from blood and casts with only a 
small amount of albumen present, as well as when the 
urine is scanty in amount and contains an abundance of 
albumen. Amaurosis is frequent. Derangements of the 
alimentary tract are often noticed. The duration of the 
disease varies from two to several weeks; in some cases 
it is months before recovery is complete and albumen and 
casts cease to appear in the urine. As resolution occurs, 
the skin which was dry and hot becomes moist, the urine 
pale and more copious, the dropsy disappearing slowly, 
though it may do so rapidly by critical discharges from the 
bowels and kidneys. 

In acute parenchymatous nephritis from non-infectious 
bacteria there is moderate fever, and the urine contains a 
small quantity of albumen, a few leucocytes and red blood 
corpuscles, with a large number of bacteria. These cases 
are usually mild in character and last from one to six 
weeks. 

The malarial form may be of the exudative or productive 
variety, and is characterized by the large quantity of blood 
in the urine. Recurrent attacks are apt to be frequent un- 
less the patient is at once removed from the malarial region. 

In diphtheritic nephritis the dropsy is never marked, 
cardiac hypertrophy does not develop, the disease usually 



ACUTE PARENCHYMATOUS NEPHRITIS. 199 

runs a rapid course and terminates in recovery. If it is of 
the exudative variety, the urine rarely contains blood casts 
or corpuscles and the specific gravity is never high. 

As a complication or sequela of typhoid fever, it is 
usually accompanied by catarrh of the urinary tract, and 
makes its appearance during the second week of the dis- 
ease. Bodin, in N. Y. Medical Journal, Aug. n, 1894, 
describes three varieties : 1. One in which albumen 
appears more or less abundantly in the urine, with sup- 
pression of urine, oedema and symptoms of acute uraemia, 
terminating fatally with coma or convulsions. 2. A 
variety less violent, but always grave ; urine diminished in 
quantity, albuminous, and containing blood. 3. The 
most frequent ; characterized by aggravation of the gen- 
eral condition, dryness of the tongue, pain in the loins, 
headache, and the appearance >of a small quantity of albu- 
men in the urine. The urine in this variety of acute 
parenchymatous nephritis frequently contains micrococci, 
with or without the bacillus of Eberth, streptococci and 
staphylococci. It is believed that these bacteria enter into 
the blood from the intestines through intestinal ulcer- 
ation. 

In relapsing fever there is an abundance of desquamated 
renal epithelia in the urine. When the disease occurs as 
the result of exposure to cold and dampness, it is usually 
ushered in by a chill, followed by high fever, pain in the 
back and rapidly developing dropsy. When from scarlet 
fever it generally makes its appearance between the second 
and sixth week of the disease, and is announced by nausea, 
vomiting, diminished secretion of urine and headache. 
When of toxic origin, it is accompanied by frequent mic- 
turition, bloody urine, and the general symptoms of an 
acute cystitis. 

There is a form of acute exudative nephritis which de- 
serves special notice, and which is characterized by the 



200 UROPOIETIC DISEASES. 

presence in the urine, in addition to the usual elements 
found in nephritis, of a large quantity of pus cells, which 
do not occur as the result of an associated cystitis but are 
due to the excessive violence of the nephritic inflamma- 
tion. It occurs in some of the infectious diseases both in 
childhood and in adults. The symptoms appear suddenly 
and with great intensity. Restlessness, delirium, coma 
and convulsions are marked, dropsy is absent or slight, 
prostration appears early and progresses rapidly, followed 
by a typhoid state and death. There are but few recov- 
eries. This form is believed to be due to some unknown 
micro-organism. 

Prognosis. — The prognosis in acute exudative nephritis 
is far better than in acute productive nephritis. In the 
acute exudative variety, when the cerebral symptoms are 
not prominent and the disease pursues the ordinary course, 
a favorable termination may be looked for. When grave 
cerebral manifestations are present — headache, restlessness, 
delirium, coma, and convulsions — the prognosis must be 
guarded, though it is sometimes favorable even in the 
most alarming cases; much, however, depends upon the 
exciting cause. When, on account of the severity of the 
inflammation, pus cells appear in the urine in large num- 
bers, the prognosis is very unfavorable. When from inter- 
mittent fever, exposure to cold or from diphtheria, the 
prognosis is good. When of the acute productive va- 
riety, the prognosis is not very propitious, even when the 
patient does not present serious symptoms. Either death 
will occur in a few days, weeks or months, or after numer- 
ous exacerbations and apparent recoveries the condition 
passes into a chronic and incurable state. In the post- 
scarlatinal form, the majority of deaths occur either from 
ursemic complications or from heart failure due to acute 
cardiac dilatation. Uraemia is not necessarily fatal. Pul- 
monary oedema, oedema glottidis, hydro-thorax, hydro- 



ACUTE PARENCHYMATOUS NEPHRITIS. 201 

pericardium, ascites, and the occurrence of local inflamma- 
tions in the pleura, lungs, or peritoneum are serious 
complications and liable to cause death. 

Anuria, when persistent, generally indicates a fatal 
termination, though it sometimes continues for days with- 
out producing unfavorable symptoms. The danger in acute 
nephritis depends upon the impairment of the excretory 
power of the kidneys and the consequent retention of 
water and nitrogenous substances in the system which 
should have been eliminated. 

Treatment. — In the early stage of acute exudative 
nephritis, Aconite, Belladonna, or Veratrum vir. are fre- 
quently indicated; later, Cantharides, Rhus tox., Apis, 
Helleborus nig., or Apocynum can. If of the productive 
variety, Mercurius corr., Arsenicum or Plumbum carb. 
Uraemic symptoms and convulsions will call for Cuprum 
ars., Cicuta vir., Stramonium, Cannabis ind., Carbolic ac, 
Ammonium carb., Hyoscyamus, etc. 

Aconitum napellus : Acute nephritis from cold or sec- 
ondary to scarlet fever, with rapid development of anasarca 
high fever, restlessness, with soreness in the lumbar region 
The pulse may be small and tense, with general feeling 
of anxiety, irritable stomach, surface of the body cool ; the 
patients starts from sleep in agony with cold sweat on fore- 
head and limbs. 

Apis mellifica : Acute nephritis complicating scarlet fever 
or pregnancy. The dropsical conditions develop rapidly ; 
the cedematous parts have a waxy hue. There is no thirst ; 
limbs and back ache. Mental condition dull ; tonic and 
clonic spasms. All symptoms are worse the latter part of 
the night, and are relieved when sitting erect. 

Apocynum cannabinum : Causes increased blood pressure 
and congestion of the kidneys. It has been called the vege- 
table trocar — from the rapidity with which general drop- 
sies disappear when it is administered in appreciable doses, 



202 UROPOIETIC DISEASES. 

t. <?., two drop doses of the tincture in a dram of water 
every hour, or, better yet, one-half dram doses of a fresh 
infusion. This remedy is indicated in acute nephritis 
with scanty, dark-colored urine. There is great thirst, but 
water nauseates ; oppression in the epigastrium and chest ; 
pulse irregular, intermittent and feeble ; stupor, with con- 
stant automatic movements of one arm or leg. 

Arsenicum album : Is rarely indicated in the exudative 
variety, but is invaluable in the productive form of acute 
nephritis. When dropsical conditions are present, all symp- 
toms are sub-acute, with progressive weakness, anxiety, 
restlessness, uraemia, and thirst for small quantities of fluid. 
Dyspnoea, either from cardiac weakness or oedema of the 
lungs, worse on lying down, especially recurring at or after 
midnight, and relieved by expectoration. Goodno says he 
obtains the best results from this remedy when he admin- 
isters it in the form of Fowler's solution, drop doses every 
four to eight hours. 

Belladonna : Acute parenchymatous nephritis with 
flushed face, fever, and possibly delirium, characterized by 
tendency to strike and bite. This remedy relieves the con- 
gestion of the Malpighian capillaries, but does not affect 
the secreting epithelium of the convoluted tubes. Large 
doses aggravate ; the medium potencies give rapid relief. 

Cantharides: Following the antiphlogistics, Aconite, 
Belladonna, Veratrum viride, etc., this becomes one of the 
most potent remedies, especially in the nephritis of scarlet 
fever and diphtheria. Dr. Dessau, Med. Times, 1895, 
quotes Prof. Cornil, London Practitioner, Vol. 27, P. no, 
who says : " When the kidney of dogs and rabbits, 
poisoned with Cantharides, produced a nephritis it was 
impossible to distinguish it from a condition of the kidney 
found in children dying from the nephritis of scarlet fever 
or diphtheria. These observations will be quoted in full, 
as they give perfect indications for the remedy in acute 



ACUTE PARENCHYMATOUS NEPHRITIS. 203 

parenchymatous nephritis. He observed intense conges- 
tion affecting the glomeruli, increased tension of the blood 
in the vessels, the passage through their walls of its liquid 
constituents, of serum carrying granules along with it, and 
some red and white blood corpuscles which accumulate in 
large numbers in the glomerulus. At a later stage the 
inflammation shows itself in the straight and convoluted 
tubes by multiplication of the cells and modification of 
their form and migration of leucocytes." Pain in the 
region of the kidneys, loins and abdomen, with constant 
desire to urinate. Burning, stinging and tearing pains in 
the region of the kidneys, uraemia, delirium and coma, 
with high fever, and hard, frequent pulse. 

Cicuta virosa : Is beneficial in ursemic conditions, char- 
acterized by the twitching of individual muscles. 

Cuprum arsenicosum : Goodno says : " For ursemic symp- 
toms in acute nephritis, unless contra-indicated, I now ad- 
minister this drug in the second or third decimal trituration, 
in three-grain doses, repeated every half hour to two hours 
until the symptoms subside. The remedy possesses a most 
remarkable influence over ursemic Convulsions. In quite 
a number of typical cases seen by him and others, its use 
has been followed, even in desperate cases, by the dis- 
appearance of the convulsions, improvement being usually 
apparent in from two to four hours." The experiments of 
the Central Homoeopathic Society of Germany show con- 
clusively that this remedy causes renal inflammation and 
degeneration of the epithelium of the tubules of the kid- 
ney, with scanty and albuminous urine. 

Helleborus niger: This remedy is especially useful in 
post-scarlatinal nephritis with dropsy, scanty high-colored 
urine, with or without mental stupor from ursemic condi- 
tions. Five-drop doses of the tincture in water every two 
to four hours will act rapidly in the sudden dropsies of 
acute nephritis. 



204 UROPOIETIC DISEASES. 

Mental torpor predominates, pupils dilated, the eyes do 
not react to light, and while the patient sees imperfectly 
he does not comprehend what he sees. Violent pains in 
the head — so severe as to cause constant change of position 
— dull pain in occipital region, worse on stooping ; nausea, 
vomiting, absence of thirst ; convulsions, with cold extremi- 
ties ; dropsical conditions, with frequent desire to urinate. 

Mercurius corrosivus : This is indicated in the productive 
form of nephritis. It cures inflammation of the kidneys, 
acute congestion, or inflammation of the secreting portion. 
The urine is blackish, scanty, or completely suppressed, 
and contains albumen, blood corpuscles, and granular and 
fatty casts. The epithelial cells from the uriniferous 
tubules are found to be in a state of fatty or granular 
degeneration. Goodno says "The patient looks wretched, 
is anaemic, short of breath, the urine is highly albuminous, 
and micturition is frequent. It acts best after the dropsy 
has subsided somewhat, or is not a prominent feature." 
The third trituration has been found the most efficacious. 

Rhus toxicodendren : Goodno says : " After subsidence of 
the initial hyperaemia; I have found this medicine useful 
in cases not marked by dropsy. In idiopathic nephritis; 
in nephritis clearly attributable to exposure to cold and 
damp, especially when brought on by getting wet during a 
cold rain ; in nephritis ushered in by much pain in the back 
and general soreness or aching, also in some cases follow- 
ing scarlatina without these conditions." He advises the 
tincture in one-fourth drop doses hourly. 

Terebinthina : This remedy will be found especially 
useful in acute croupous nephritis from colds and malarial 
conditions. From its pathogenesis it is only indicated 
when blood is found in the urine. Its main influence is 
expended upon the Malpighian bodies. The urine is 
scanty, smoky, bloody or almost suppressed ; dropsy may 
be absent. It is rarely indicated in cases where ursemic 
symptoms are present. 



ACUTE PARENCHYMATOUS NEPHRITIS. 205 

Veratrum viride : This is required for the congestion of 
the cerebral vessels, for the convulsions in the early stage 
and during the course of acute parenchymatous nephritis. 
When indicated by the increased arterial tension, high 
temperature, and thin, small pulse with troublesome vomit- 
ing, it quickly relieves the symptoms. 

In addition to the above, Cannabis ind., Plumbum carb., 
Chelidonium, Colchicum, Sabina, Scilla, Veratrum alb., 
Antimonium tart., Bryonia alb., Nitric ac, Glonoin, etc., 
may be required. For special and more complete indica- 
tions see chapter on renal therapeutics. 

This disease may often be prevented by the observance 
of proper hygiene and care in the administration of certain 
irritating drugs, as Cantharides, Turpentine, etc., but it 
is impossible when it occurs as a complication of the 
infectious diseases or when of bacterial origin, except in 
protecting the patient from exposure, etc. 

In all cases warmth should be applied, but not sufficient 
to produce sweating. The sick room must be kept at a 
temperature of 72 to 74 ° F.,and the exposure of the patient 
to draughts of air, even over the bed, carefully guarded 
against. The patient should remain in bed, between flan- 
nel sheets, clothed in flannel until all, or nearly all, the al- 
bumen has disappeared from the urine and the other 
symptoms have abated. In many cases the mere fact of 
the patient sitting up after the albumen has disappeared 
from the urine has caused an excerabation of the disease 
and a return of the albumen. 

Warm baths daily, at ioo° to 105 F., lasting from five 
to fifteen minutes, followed by rest and quiet for one or 
two hours, or hot packs once or twice a day, given by 
wrapping the patient for an hour in a flannel blanket 
wrung out of hot water, are very necessary to remove 
dropsical effusions. 

In many of the more critical cases, hot air baths are in- 



206 UROPOIETIC DISEASES. 

dicated, and are of great service. Air heated by means 
of an alcohol lamp placed at the side of the bed is con- 
ducted between the blankets covering the patient through 
two lengths of stove-pipe with an elbow. The whole 
body should be daily sponged with tepid water, under the 
bed clothes, to assist diaphoresis and give comfort to the 
patient. Dry cups, from two to twelve in number, applied 
over the kidney region once or twice daily are sometimes 
useful in relieving the local congestion. Hot Boric acid 
stupes, applied hourly, and covered with oiled silk, are 
often of great service. The bowels must receive proper 
attention ; if constipation is present, the unloading of the 
venous capillaries may be produced and the abdominal 
circulation decidedly improved by drachm doses of Mag- 
nesia sulphate every hour until eight doses have been 
given, or there is an evacuation. The better way, how- 
ever, to relieve the constipation and the stagnation of the 
circulation is to flush the rectum daily with two to four 
quarts of hot water at a temperature of 102 to 105 F. 
In many cases a portion of the water is retained, absorbed 
and excreted by the kidneys. 

Milk is the classical food, not only because it contains 
all the body-building principles, but because it seems to 
possess a diuretic action. It can be varied to advantage 
with Hudson's food, malted milk, buttermilk, kumyss, 
matzoon, and usually some animal broths. If ursemic 
symptoms appear, nitrogenous food of every description 
must be avoided. Poland, Stafford, Clysmic, distilled, 
or any pure water, must be ingested in large quantities, in 
order to flush the kidneys, and at the same time remove 
the solid constituents from the blood. In the treatment of 
acute parenchymatous nephritis, it is important to increase 
the quantity of the watery and nitrogenous excretions 
from the kidneys, which are usually greatly diminished, 
and which, if neglected, accumulate in the system, pro- 



ACUTE PARENCHYMATOUS NEPHRITIS. 207 

ducing headache, convulsions, coma, and dropsical accum- 
ulations. Diuretics {per se), while relieving sometimes, 
as a rule increase the inflammation in the kidney, and do 
more harm than good. They are as harmful as cathartics 
in the very acute cases. In productive nephritis, Digitalis, 
Caffein, Strophanthus, Diuretin, Acetate of potash, Squilla, 
etc., may be used in appreciable doses as a makeshift. 
The hydragogue cathartics, Jalap, Klaterin, etc., some- 
times give rapid results, but they cannot be continued, 
as they will eventually irritate the stomach and exhaust 
the patient. The arterial tension should at all times be 
carefully watched, and the timely administration of 
Aconite, Belladonna, Glonoin, Amyl nitrate, Chloral 
hydrate, etc., will often avert many of the more serious 
symptoms. 

If convulsions occur, Chloroform, by inhalation, may be 
given for immediate relief, or rectal enemas containing 
ten to twenty grains of Chloral hydrate with twenty to 
sixty grains of Potassium bromide may be used. When 
heart failure is imminent, Digitalis, two or three drops of the 
fluid extract, or Caffein, Strophanthus, Spartein or Glonoin 
will be required. When all forms of medicinal treatment 
fail and the cavities of the body are filled with dropsical 
fluid and the connective tissue is infiltrated to a marked 
degree, punctures into the dependent parts, or tapping of 
the cavities, under strict asepsis, is often necessary. 

When the disease is of the exudative variety, as health 
returns solid food may be gradually allowed and the 
usual duties of life resumed ; but if it is believed to be of 
the productive type, treatment must be continued for 
months, a warm, equable climate advised, with freedom 
from mental and physical fatigue, together with some light 
outdoor employment or recreation. 

Dr. Reginald Harrison, Medical Record, Nov. 7, 1896, 
records a number of apparent cures of acute productive 



208 UROPOIETIC DISEASES. 

nephritis by surgical methods. He gives two conditions 
in which surgical interference is indicated. 

i. Includes those instances in which the kidney com- 
plications are, from the onset, of the gravest character and 
death is imminent. In these cases a fatal termination 
usually rapidly ensues, the duration of life being largely 
determined by the degree of urinary suppression. 

2. A group of cases including those in which, after a 
limited time, the tendency, so far as the renal symptoms 
are concerned, is not in the direction of recovery. The 
amount of albumen does not decrease, tube casts, as well 
as other evidence of deterioration, are in the urine, and 
the quantity of urine excreted is below what may be re- 
garded as a fair average. Tenderness over the kidney on 
pressure is often complained of. 

That many cases of nephritis with high tension and 
subsequent structural deterioration must necessarily be 
attended by cardiac hypertrophy is obvious. Diminished 
capacity of the excreting power of the kidneys can only be 
compensated for by increase in the force of the blood cur- 
rent. In the restoration of the function of the kidney we 
have the only safeguard against the development of this 
complication. In the surgical treatment of renal tension 
associated with albuminuria, the kidney should be exposed 
by a moderate incision, so as to enable the operator to feel 
the organ distinctly, both in front and behind, aided, of 
course, by the hand of an assistant pressing the abdomen 
backwards from the front. If in conjunction with the 
presence of albumen in the urine the kidney is found to 
be in a state of tension, three or four punctures should be 
made in the capsule in various directions. Should the 
organ be found to be in a higher state of tension, a longi- 
tudinal incision into the cortex along the convex surface, 
one or two inches in length should be made, a drain- 
age tube inserted and the wound lightly packed with 



CHRONIC PARENCHYMATOUS NEPHRITIS. 209 

Iodoform gauze. The incision should be dressed in such 
a manner as to provide for the free escape of blood, urine, 
etc. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

Chronic Productive Nephritis with Exudation, Chronic 
Croupous or Tubal Nephritis, Chronic Glomerulo Nephritis, 
Chronic Desquamative Nephritis, etc. 

Delafield defines it as a chronic inflammation of the 
kidney attended with a growth of new connective tissue in 
the stroma, permanent changes in the glomeruli, degenera- 
tion of the renal epithelium, with exudation from the 
blood vessels, and sometimes changes in the wall of the 
arteries. It is characterized by dropsy and albuminous 
urine, both well marked. 

Etiology. — It often follows acute productive paren- 
chymatous nephritis, and is frequently produced by ma- 
larial diseases, exposure to cold and damp, particularly 
damp and unhealthy dwellings, grief, worry, etc. In some 
cases it comes on very insidiously, without apparent cause, 
especially in middle life, at which period it is most preva- 
lent. It also occurs in certain blood dyscrasias, as rheu- 
matism, gout, etc. 

Pathological Anatomy. — The kidneys in their gross 
appearance show a variety of forms. The most common 
is a large white kidney, with a thick white cortex, or the 
cortex may be mottled red and white or red and yellow. 
The kidneys may be apparently normal, except that 
their capsules are adherent ; they may be small, with a 
white or red cortex. The surfaces may be smooth or 
nodular ; the nodules may be large or fine, covering the 
whole surface. The capsules are not always adherent, even 
in some of the small contracted kidneys. The cortex is 
often irregularly thickened ; in some places it may be 
thinned and in others so thickened as to obliterate a part 
14 



210 UROPOIETIC DISEASES. 

or the whole of a pyramid. In the cortex the growth of 
connective tissne is abundant, in some portions to such an 
extent as to cause an atrophy of a large number of tubules : 
in other portions of the cortex the tubules may retain 
their normal size or be dilated. The epithelial cells lin- 
ing the tubes are in some places flattened and in others 
swollen. The tubes contain granular matter, fibrin, leuco- 
cytes and red blood cells, or they may be empty. In the 
glomeruli there may be a proliferation of the lining ceils. 
This proliferation of cells subsequently changes to con- 
nective tissue. There may be a hyperplasia of the cells 
covering the capillary tufts, often to such an extent as to 
fill the glomerulus. The glomeruli are sometimes en- 
larged ; they may be atrophied. The arteries may undergo 
an inflammation involving all three coats, or there may 
be a calcareous degeneration of the inner coat. 

Clinical History. — It has many symptoms in common 
with acute productive parenchymatous nephritis. Its 
course is chronic, varying from a few months to many 
years, and frequently follows an acute or sub-acute pro- 
ductive nephritis. Often however, there are numerous 
exacerbations, the result of excesses, cold, damp, preg- 
nancy, rheumatism, etc. 

The dropsy, which varies from a slight oedema of the 
eyelids, feet and hands, to marked general anasarca, is one 
of the early — if not the earliest — symptoms noticed by the 
patient. This dropsical condition, like that in acute par- 
chymatous nephritis, does not depend upon the anatomical 
location for its special appearance, but may, in different 
cases, appear in various locations, and may even change 
its position. It may be so extensive as to cause sloughing 
of the parts. The effusion of blood-serum into the tissues 
is due to the same causes which allow of its exudation 
with the urine. Seminola. in 1881, demonstrated that the 
blood-serum in chronic parenchymatous nephritis had a 




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*'•! ' 



^i 



(MAGNIFIED 450 DIAMETERS.) 

FIG. I. 

CHRONIC PARENCHYMATOUS NEPHRITIS WITH EXUDATION. 

. Capillary tuft, with growth of epithelium, b. Hyperplasia of lining cells of glomerulus. 

c. Tubule, with partially destroyed epithelium, d. Tubules, containing exudate 

and detached epithelium, e. New connective tissue growth in stroma. 





*• - VJ — 










(MAGNIFIED 450 DIAMETERS. ) 
FIG. 2. 

CHRONIC PARENCHYMATOUS NEPHRITIS WITH EXUDATION. 

a. Convoluted tubules, with partially destroyed epithelium, containing exudate, b. Same as a, 

with epithelium detached, c. Tubule, dilated, and epithelium flattened, d. New 

connective tissue growth in stroma. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 211 

greater power of diffusion than in health or in the cirrhotic 
form of nephritis. 

The second most noticeable and most marked constant 
symptom is the anaemia ; the accompanying pallor is 
sometimes described as the statesman's complexion. It is 
progressive, due to changes taking place in the blood i. e. 
the red and white blood corpuscles are gradually reduced 
in absolute and relative numbers, the fibrin remains about 
normal, while the amount of albumen fluctuates to a con- 
siderable degree, but is always much below the healthy 
average ; at the same time it is charged with the nitro- 
genous products of alimentation, which the kidneys in 
their impaired state have been unable to excrete. This 
condition of the blood plays an important part in produc- 
ing the dyspnoea, nausea, indigestion, headache and pros- 
tration which mark the disease. At first emaciation is 
not noticeable, as the general anasarca obscures it to a 
great degree ; later, as atrophy of the kidney is developed, 
the oedema will somewhat subside, and the emaciation in 
consequence become very apparent. 

Micturition is increased in frequency, though the quan- 
tity of urine voided during the day will usually be some- 
what reduced. The specific gravity of the urine is lowered ; 
generally it is about ioio, due to reduction in the per- 
centage of urea; it may, however, be greatly increased. 
It is observed that in those cases which run a rapid course, 
that the specific gravity is higher, 1012-1020, than in the 
more chronic, when it is about 1001-1006. A low specific 
gravity indicates a large growth of connective tissue in the 
cortex of the kidney. The acidity of the urine is below 
the average, albumen is present in abundance, urea is 
diminished, uric acid is about normal, casts are numerous. 
Granular casts are considered characteristic of this form 
of kidney disease, although hyaline, waxy and fatty 
casts are sometimes present. The hyaline may be either 



212 UROP£>IETIC DISEASES. 

large or small, and they, with the lighter colored granu- 
lar casts, appear early in the disease, while later the 
majority are dark, granular, waxy or fatty. Blood casts 
and those well covered by epithelium are rarely met 
with in this form of Bright's disease unless an acute 
attack of nephritis has supervened. The predominance 
of certain casts determines the diagnosis and the patho- 
logical state of the kidneys. Whenever blood corpuscles, 
pus and epithelial cells are found in the urine, they are 
evidence that an acute attack has been added to the 
chronic inflammation of the kidney tissue. If atrophic 
changes take place in the latter stage of chronic parenchy- 
matous nephritis, the quantity of urine will be increased 
and its specific gravity relatively diminished. The heart 
is rarely affected, cardiac dilatation and hypertrophy are 
uncommon, and, if present, are not usually noticed during 
life. 

Cerebral haemorrhages and epistaxis are uncommon. 
Dyspnoea is frequent ; when it is present, and not due to 
disease of the lungs or heart, the urine should always be 
examined. It may be of uraemic origin, caused by gen- 
eral anaemia or dropsical accumulations. It may be con- 
tinuous or transitory, especially at night or in the early 
morning, and is always worse when the patient assumes a 
recumbent position. 

Loss of sight sometimes occurs, due to albuminuric 
retinitis; it may be transient or permanent ; both eyes are 
usually affected. Headache is a common accompaniment ; 
it may be confined to the fifth, pair of nerves or appear as a 
migraine with nausea and vomiting. 

Rheumatic pains sometimes accompany the oedema of 
the muscles. They are usually dull but sometimes shoot- 
ing in character, and are not relieved or aggravated by mo- 
tion or pressure. Pains in the regions of the kidneys are 
rare. Anaesthesia of the fingers, usually of the left hand, 



CHRONIC PARENCHYMATOUS NEPHRITIS. 213 

sometimes occurs. Fever is never present unless an acute 
Bright's disease has been added to the chronic condition. 
Bronchial symptoms are never absent in well-marked 
cases of chronic parenchymatous nephritis. Flatulent indi- 
gestion, vomiting and diarrhoea are frequent ; the tongue 
is usually clean. Ursemic convulsions are uncommon. 

This form of Bright's disease is essentially that of middle 
life, rarely occuring after the fiftieth year. 

Diagnosis. — This is usually easy, especially when the ge- 
neric symptoms are pronounced, i. <?., extensive dropsy, with 
diminished quantity of the urine of low specific gravity, 
albuminuria and an abundance of granular and fatty 
casts, together with the absence of distinct cardiac lesion. 
When contraction (atrophy) of the kidney has developed, 
causing increased cardiac action and consequent hyper- 
trophy, it is sometimes impossible to differentiate this con- 
dition from the interstitial variety of chronic Bright's 
disease. 

Prognosis. — Unfavorable ; complete restoration to health 
is rare. The younger the patient, the more favorable the 
prognosis. That some cases, even when of long standing, 
terminate in recovery there is not the slightest doubt, but 
everything depends on the amount of kidney tissue in- 
volved, the treatment and hygiene advised, and the way it 
is followed. When of syphilitic origin, the prognosis is 
favorable ; when from scrofula, it is unpropituous. When 
the relative quantity of albumen is over I per cent, by 
weight and the number of granular, waxy and fatty casts is 
large, the prognosis is unfavorable. It is more promising 
when the hyaline casts predominate. Loss of sight, due to 
albuminuric retinitis may improve somewhat but com- 
plete recovery is rare. 

Treatment. — Arsenicum album acts well in chronic ne- 
phritis caused by scarlet fever and malaria, and especially 
in the large, fatty variety. Great anxiety is always present, 



214 UROPOIETIC DISEASES. 

with great despair, sure they are about to die ; rapid sink- 
ing of strength, and emaciation ; general cederna, begin- 
ning with puffiness of the eyes and extremities ; palpitation 
of the heart, cardiac dyspnoea, dyspnoea from oedema of the 
lungs, increased by lying down, especially recurring at 
midnight ; skin feels cool, while they complain of thirst ; 
water irritates the stomach, and causes vomiting. All 
symptoms relieved by warmth. 

Cantharides is useful in the early stage of chronic 
nephritis — relieving tfhe headache, delirium, coma, etc. 
The urine is scanty, dark, and contains albumen, epithelia 
and casts from the tubuli-uriniferi. Mental stupor ; draw- 
ing, tearing pains in region of the kidney ; lumbar region 
sensitive to touch ; thirst, fluids do not affect the stomach, 
but they increase the pain in bladder and frequency of 
urination. 

Ferrum muriaticum will be indicated in proportion as 
the hepatic, digestive and assimilative functions are normal, 
and the albuminous process is remote from or independant 
of recent congestion, debility, with pale face that flushes 
easily ; feeble action of the heart, occasionally losing a 
beat, together with pain in lumbar region, relieved by 
walking, aggravated by sitting. 

Kali muriaticum : Goodno reports excellent results with 
this remedy in Bright's disease, with progressive anaemia 
and prostration. The patient is pale, breathless, with cardiac 
palpitation, urine scanty, high-colored and albuminous. 

Mercurius corrosivus : General oedema of the body. 
Earthy pallor of the skin ; anorexia ; nausea, with weak- 
ness, and tenderness in the epigastric region ; pulse quick 
and feeble, great weakness and prostration, restlessness of 
the limbs, must change position frequently ; perspiration 
on slight exertion ; coma and convulsions. All symptoms 
worse at night and after sleep. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 215 

Nitric acidicum : Great weakness, especially in the 
morning. Bright's disease, with gastric disturbances. 

Nnx vomica : Bright's disease, with digestive disturb- 
ances ; patient irritable, morose, desires to be alone ; symp- 
toms relieved by keeping quiet. 

Phosphorus is invaluable in the stage of fatty degenera- 
tion when fatty casts appear in the urine, frequently asso- 
ciated with a weak, empty feeling in the whole abdomen ; 
weakness of memory, etc. 

For the acute exacerbations, the remedies already given 
under acute parenchymatous nephritis must be consulted. 
For other remedies see chapter on therapeutics. 

Hygiene is of the utmost importance. The body should 
at all times be clothed with woolen or silken under- 
garments, warm but light in weight, and sufficient to 
prevent sudden chilling of the surface from rapid at- 
mospheric changes. The patients need not be confined to 
their beds, though it has been demonstrated repeatedly 
that the albumen diminishes and casts in the urine be- 
come less numerous, when from any cause nephritic cases 
are compelled to remain in bed. When possible, without 
endangering the health, removal to a warm equable climate 
will be advantageous. When this is impossible, the 
patient should remain indoors in inclement weather. 
Moderate exercise of body and mind should be encouraged, 
and regular and sufficient sleep taken, but excesses of all 
kinds must be avoided. 

A strict milk diet is frequently of great benefit, though 
few will follow it for any length of time. Germain See 
advises the ingestion of large quantities of milk — from two 
to four quarts daily ; he says that albumen frequently dis- 
appears under this regimen, and does not return when a 
more generous diet is allowed. The usual practice is to 
advise a moderate daily allowance of milk, with a mixed, 
though somewhat selected, diet. Hale White says an 



216 UROPOIETIC DISEASES. 

ordinary full diet, in his experience, does not increase the 
tendency to ursemic symptoms. Highly seasoned food, 
smoked meats and alcohol in all forms must be forbidden. 
It should, however, always be remembered that, in this 
form of chronic Bright's disease, the condition of the kid- 
neys is such that their secreting power is impaired, and they 
cannot be expected to do their usual quota of work ; conse- 
quently a diet which will produce the smallest amount of 
urea, sustain the strength of the patient, and at the same 
time build tissue, should be chosen. Physiology teaches 
that the amount of urea secreted is always in proportion 
to the quantity of nitrogenous food ingested ; it is, there- 
fore, evident that this class of food should constitute only 
a small or very moderate proportion of the daily aliment. 
Experiments have proved that non-nitrogenous food 
reduces the daily quantity of urea secreted and increases 
the quantity of watery elements ; it should, consequently, 
be advocated in order to reduce the quantity of urea and 
increase the amount of water. A large portion of the 
residue of the carbo-hydrates are expelled by the bowels 
and the skin ; they can, therefore, be allowed in generous 
quantities. 

Hirschfield allows as a typical daily diet in this disease 
six ounces of meat, thirteen ounces of bread, a liberal 
allowance of vegetables and fruit, one and a half ounces 
of sugar, and five ounces of fat. When the urine becomes 
scanty and high-colored, with more or less sediment, an 
increase in the quantity of water ingested will be of posi- 
tive benefit, not only by increasing the quantity of urine, 
but by washing out the secreting portion of the kidney. 
The waters usually recommended are Poland, Stafford, 
Waukesha, Clysmic, Hygeia, or any other pure or distilled 
water. In some cases saline waters will be required. The 
dropsical condition may be relieved by the appropriate 
remedy, but the hot air bath or pack is sometimes re- 



CHRONIC PARENCHYMATOUS NEPHRITIS. 217 

quired. A warm bath at bed-time, beginning at a tem- 
perature agreeable to the patient, which is gradually in- 
creased to 105 F., and continued, from ten to twenty 
minutes, causes a diminution of the dropsical accumu- 
lations, and in a few hours the flow of urine in- 
creases. Morning sponge-baths, followed by general 
friction, are beneficial. Acute exacerbations are to be 
treated on the principles advised for acute parenchymatous 
nephritis. 

The condition of the heart, pulse, and respiration de- 
serve special attention. Whenever the pulse indicates 
increased arterial tension, and it cannot be relieved by the 
selected remedy, we can on physiological grounds prescribe 
Nitro-glycerin, Chloral hydrate, Morphia, or Potassium 
iodide. If this condition is neglected or passes unnoticed, 
vomiting, headache, dyspnoea and convulsions will soon 
appear. The administration of Opium is admissible only 
when tension of the arterial system is present. Should the 
dropsical condition persist in spite of treatment, it may be 
necessary to give from one to four teaspoonfuls of the In- 
fusion of Digitalis, freshly prepared from English leaves, 
every three or four hours ; two-drop doses of the tincture 
of Apocynum can. every hour, or, preferably, a teaspoon- 
ful of the infusion of the fresh root. Pilocarpin has 
sometimes been of benefit, but it is decidedly contra- 
indicated where heart weakness to any degree is present. 
L,arge dropsical accumulations may require removal with 
the aspirator, or by scarification, under strict asepsis, of the 
cellular tissue in the most dependent portions of the body. 
Dyspnoea, caused either by arterial tension or dropsical 
accumulations, is usually amenable to drug treatment. 



218 UROPOIETIC DISEASES. 



INTERSTITIAL NEPHRITIS. 

Renal Cirrhosis, Renal Sclerosis, Granular Atrophy, Red 
Granular Nephritis, Gouty Kidney, Chronic Interstitial 
Nephritis, Contracted Kidney and Catarrhal Nephritis. 

Delafield defines it as a chronic inflammation of the kid- 
ney, attended with a new growth of connective tissue in 
the stroma, permanent changes in the stroma and glom- 
eruli, degeneration of the renal epithelium and sometimes 
changes in the walls of the arteries. 

It has usually been considered pre-eminently an insid- 
ious and chronic disease, but later investigations demon- 
strate it to be in many cases of catarrhal origin and acute 
in nature. Virchow says : u There is first infiltration of 
the connective tissue, with cloudiness and swelling of the 
epithelium, followed by desquamation, the oedema being 
most marked between the cortical and pyramidal sub- 
stances." 

Etiology. — Under the old pathology, the cause in the 
majority of cases was believed to be obscure or undiscover- 
able, but with the more perfect knowledge gained by care- 
ful investigation it is apparent that cold, exposure and 
dampness are important factors in the origin of interstitial 
nephritis, the symptoms of which are so slight and trivial 
in the early stages that they frequently pass unnoticed. 

It was believed by many authors that indulgence in 
alcoholic beverages was the prime factor in the causation 
of this disease, but statistics prove beyond a question that, 
interstitial nephritis occurs less frequently in those who 
take alcohol in moderation than in the strictly temperate ; 
yet it is not infrequent when the system has been satu- 
rated with alcohol, producing cirrhosis of the liver, that 
the autopsy also gives evidence of an associated contracted 
kidney. Climate has its effect ; the disease is essentially 



t-H 



(MAGNIFIED 450 DIAMETERS.) 

CHRONIC INTERSTITIAL NEPHRITIS. 
a. Capillary tuft, and atrophied glomerulus, b. Atrophied tubules, with detached epithelium. 
c. Connective tissue growth. 






/- 



I — c 



(MAGNIFIED 450 DIAMETERS.) 
CHRONIC INTERSTITIAL NEPHRITIS. 
Atrophied glomerulus, b. Faint remnant of capillary tuft. c. Connective tissue growth. 
d. Atrophied tubule, c. Dilated tubule, with flattened epithelium. 

f. Atrophied tubules, with detached epithelium. 



INTERSTITIAL NEPHRITIS. 219 

one of the temperate zone and may be accounted for by 
the frequent and sudden atmospheric changes common 
to it. It is of infrequent occurrence in the frigid, tropic 
or sub -tropic regions. 

Malarial poisoning, not only on account of the congestion 
occurring during the paroxysm, and the irritation produced 
by the elimination through the kidney of the bile-acids, 
but because the attacks are repeated, is often an exciting 
cause. Pregnancy has been the source of many undoubted 
cases of acute and chronic interstitial nephritis, the latter 
being due frequently to the neglect of treatment during 
this critical period. Syphilis often manifests itself as an 
interstitial nephritis, when its early treatment has been 
unsuccessful or neglected. In these cases the round cell 
formation in the interstitial connective tissue may be 
general. It has even developed in persons suffering 
from hereditary syphilis. Gout is a prime factor in 
causation. Continental authorities, however, reserve the 
name of gouty kidney to interstitial nephritis, in which 
there is a deposit of urate of soda in the pyramids of the 
kidney and along the tubules, giving sections of the organ 
a striated appearance. The microscopic changes, how- 
ever, are the same in all cases, barring this one point. 
They all result in a condition which will not allow uric 
acid to be discharged by the kidneys, while urea, on the 
other hand, is voided without difficulty. 

The ingestion of lead may also produce all the patholog- 
ical changes of interstitial nephritis, and in cases of plum- 
bum poisoning the kidneys are usually involved, though not 
suspected during life. In those who have worked in the 
Arts requiring lead, and death has been due to some other 
cause, the autopsy has frequently discovered pronounced 
evidence of interstitial nephritis. In looking for this min- 
eral as a cause of interstitial nephritis, it must not only 
be searched for in professional painters, etc., but it must be 



220 UROPOIETIC DISEASES. 

remembered that there is sufficient soluble lead in many 
of the drinking waters delivered through lead pipes to pro- 
duce the disease in those who are susceptible, especially 
when the water abounds -in chlorides, nitrates, etc. Inter- 
stitial nephritis has appeared in families for generations ; 
perhaps due as much to hereditary weakness of the parts 
as to inherent family weakness, the nephritic disease being 
precipitated on the appearance of some of the exciting 
causes already mentioned. As gathered from statistics, 
the time of life at which interstitial nephritis is most 
common is between the thirtieth and sixtieth year, 
though it may occur at any time ; a few cases have been 
recorded before the fifth year. It may be considered a dis- 
ease of middle and advanced age. It appears frequently in 
those weighed down by anxiety and business cares, and, 
therefore, the question might arise as to which of the last 
two etiological factors mentioned were the most potent in 
the causation of this condition, especially when statistics 
show that the disease is much more common among the 
male than the female, i. e., in the proportion of two to one. 
Cystitis, acute and chronic ; prostatitis, simple or hyper- 
trophic ; strictures of the urethra or ureter ; calculi in the 
bladder, in the pelvis of the kidney, or in both, may, by 
their presence, produce congestion and inflammation, 
which, extending by contiguity of surface as well as by the 
interference with the urinary flow and the genito-urinary 
circulation, will, in time, cause nephritic inflammation, 
usually of the interstitial variety. Valvular lesions of the 
heart, by change in the arterial tension, are also factors 
in its production. By some it is believed to be due to a 
general arterial tension with resulting renal sclerosis, 
while others maintain that the renal obstruction is the 
original cause and the general arterial tension follows it. 
Hypertrophy of the left ventricle always occurs in this 
variety of renal disease. 



PLATE VII. 



d 



(MAGNIFIED 450 DIAMETERS.) 

CHRONIC INTERSTITIAL NEPHRITIS. 

Atrophied tubules, b. Connective tissue growth, c. Hyaline masses in tubules. 
d. Detached epithelium, imbedded in hyaline material. 



-t, 

c 



v .^ •' 



(MAGNIFIED 450 DIAMETERS.! 

CHRONIC INTERSTITIAL NEPHRITIS. 
Atrophied tubules, b. Connective I issue growth, c. Detached epithelium. 



INTERSTITIAL NEPHRITIS. 221 

Pathological Anatomy. — The kidneys are as a rule 
small, with roughened surfaces and adherent capsules. 
They may be normal in size and even large, but their sur- 
faces will be rough and capsules adherent. The cortex is 
thinned, and gray or red in color. The growth of con- 
nective tissue in the cortex is abundant and appears in 
irregular patches. In the cortex the tubes are atrophied 
or dilated. In some of the dense masses of connective 
tissue they may be completely obliterated. Their lining 
epithelium is flattened. Some of the tubes contain hya- 
line material, epithelium, fibrin and leucocytes; others are 
greatly dilated, being almost cystic in their appearance. 
Many of the glomeruli are atrophied, some are larger than 
normal. There is a hyperplasia of their lining cells and 
the epithelium covering the capillary tufts. There is a 
generally diffuse connective tissue growth in the pyra- 
midal portion. In some parts of the kidney the character- 
istic appearance of the organ may have given way com- 
pletely to the excessive connective tissue growth. 

Clinical History. — Of all inflammatory diseases of the 
kidneys none show such insidious development. The dis- 
ease is rarely suspected by the patient or the physician 
until it is well developed, or a ursemic convulsion or 
apoplectic seizure announces its presence. In the acute 
stage, it is not often diagnosticated, and the patient rarely 
calls upon his physician with this condition in mind, but 
usually to be relieved of some secondary symptom, the re- 
sult of cardiac hypertrophy, as palpitation of the heart, 
dyspnoea, etc. It is characterized, when well advanced, 
by its associated hypertrophy of . the left ventricle of the 
heart, headache, temporary amaurosis, gastro-intestinal 
disturbances, and general debility. 

Interstitial nephritis may continue for years without 
specially lowering the general tone of the body ; in fact, 
even when fully developed, the patient may enjoy com- 



222 UROPOIETIC DISEASES. 

paratively good health ; the power of endurance, however, 
gradually wanes and general debility slowly asserts itself, 
with wasting of the muscular and adipose tissues which, 
early in the disease, may seem apparently normal. The 
complexion becomes sallow and anaemic, and headaches 
common. For this reason in all cases of persistent head- 
ache which are not readily explained a "rigid and fre- 
quently repeated examination of the urine should be made 
-for evidences which might indicate an interstitial nephri- 
tis. The headaches are persistent and often severe and 
agonizing, and are usually accompanied by dull, deep 
muscular pains referred to various parts of the body ; some- 
times confined to the back of one leg and therefore fre- 
quently incorrectly ascribed to sciatic rheumatism. As the 
disease advances, the gradual obstruction to the circulation 
through the kidneys from the progressive contraction of 
the kidney tissue and complicating arteritis produces a 
gradual increase of the cardiac hypertrophy. The hyper- 
trophy of the left ventricle has much to do with the causa- 
tion of the general symptoms, as well as the condition of 
the urine. 

As the heart responds by increased hypertrophy to the 
calls made upon it to force the blood through the dam- 
aged kidney, the headaches from arterial tension become 
more continuous, the mental symptoms more pronounced 
and the disposition of the patients radically changed. 

The cardiac hypertrophy, however, prevents dropsical 
conditions, and ascites is consequently rare in interstitial 
nephritis. Even a slight swelling of the eyelids, feet or 
hands is uncommon, unless the heart becomes weakened 
from some other cause, as over-anxiety, over- work, etc., 
but when hypertrophy ceases to compensate and dilatation 
of the heart occurs, the case being about to terminate 
fatally, dyspnoea and dropsical conditions similar to those 
in chronic parenchymatous nephritis appear. Interstitial 



PLATE VIII. 




cC 



(MAGNIFIED 450 DIAMETERS.) 

FIG. I. 

CHRONIC INTERSTITIAL NEPHRITIS. 

a. Dilated tubules, b. Detached epithelium, c. Flattened epithelium. 

d. New growth of connective tissue in stroma. 







(MA 



450 DIAMETERS.) 



SUPPURATIVE NEPHRITIS. 

a. Tubules, with degenerated epithelium, b. Tubule, tilled with pus 

c. Stroma, infiltrated with pus. 



INTERSTITIAL NEPHRITIS. 223 

nephritis is frequently associated with endocarditis and 
may remain undiscovered until pronounced changes have 
occurred in the valves, etc. 

As the disease develops the urine gradually becomes 
more abundant, pale, clear, or foamy, and acid in reaction ; 
the specific gravity varies from iooo to 1016 or even 1025. 
The relative quantity of urea is diminished, but the total 
quantity for the day usually aveiages about normal ; the 
ability to secrete uric acid is gradually lost, so that in the 
later stages no uric acid is eliminated by the kidneys. 
Casts are infrequent or absent ; when found they are of the 
small hyaline or light granular varieties, with an occasional 
leucocyte or epithelial cell attached to them ; the large 
hyaline casts are sometimes present. If, from any reason, 
an acute nephritis is engrafted upon the original disease, 
a few blood corpuscles may be present. Early in the dis- 
ease the only evidence of interstitial nephritis may be a 
few epithelial cells from the convoluted tubes of Henle. 
Later on, as the heart weakens, the casts become more 
numerous and of greater variety, as occurs in the con- 
tracted kidney of chronic parenchymatous nephritis. In 
the early period of interstitial nephritis albumen is rarely 
discovered in the urine, and later is often transitory ; fre- 
quently it is absent or undiscoverable for weeks or months 
by the most delicate tests ; hence the necessity for careful 
and long-continued search in all cases of suspected inter- 
stitial nephritis before a positive negative diagnosis is 
made. It is not uncommon for a well-developed interstitial 
nephritis to terminate fatally without albumen having been 
discovered in the urine, even after the most careful chem- 
ical examination. The amount of albumen never ex- 
ceeds 1 per cent, by weight. 

The urine is greatly increased in quantity, due to the 
increased arterial tension necessary to force the blood 
through the Malpighian bodies which remain intact, many 



224 UROPOIETIC DISEASES. 

being destroyed by the contraction of the newly-formed 
tissue. With the increased secretion of urine there is in- 
creased frequency of micturition, especially noticeable at 
night. The pulse is always hard, tense, full, and wiry. 

The cardiac hypertrophy is progressive and produces 
palpitation, causing much annoyance to the patient ; it 
may, however, in some instances pass unnoticed. As the 
disease advances, unless life is extinguished by some ex- 
traneous cause, dilatation finally occurs, and after a varied 
train of symptoms some uraemic condition will cause a 
fatal termination. 

Hemorrhages from the nasal, stomach and other mucous 
membranes are frequent, and death in one in every sixteen 
of those afflicted is due to results from rupture of a cere- 
bral vessel owing to increased tension. About one-half of 
all cerebral hemorrhages are due to recognized or unrecog- 
nized interstitial nephritis, which produces a weakened 
condition of the blood vessels of the brain, and, according 
to Charcot, the formation of small miliary aneurisms, as 
well as to a pre-existing haemophilia. Indeed, hemi- 
plegia, with or without aphasia, may be the first condition 
calling attenion to the kidney lesion. 

Autopsies have not revealed any increase in thickness of 
the cranial bones. The effect upon the eye is very marked, 
not only in the albuminuric retinitis which is frequently 
noticed by the opthaimologist long before other rational 
symptoms can be discovered, but also in a temporary 
amaurosis which may appear and disappear from time to 
time without apparent physical lesions. Uraemic symptoms 
are very common in this form of Bright's disease. 

Epileptiform seizures and muscular twitching or con- 
vulsions occur. The patient may become insane, but 
whether the insanity is dependent upon the nephritis or 
the mental condition is as yet unknown ; in some cases, 
however, the mental aberration has borne a special relation 



INTERSTITIAL NEPHRITIS. 225 

to the nephritic symptoms. Delirium, stupor or coma 
may develop rapidly or slowly. 

As the disease progresses, dyspnoea appears, sometimes 
as transitory attacks, which last for a few minutes or hours, 
and are liable to be excited by mental or physical fatigue 
or excitement, and to occur in the morning and pass off 
towards night. Ursemic symptoms gradually become more 
marked, and coma, convulsions, etc., finally cause death. 

The sexual appetite progressively diminishes as the dis- 
ease advances. Bronchitis and other chronic respiratory 
diseases are common complications. The most serious 
complication is pericarditis. 

Diagnosis. — It may be impossible in the early stage of 
interstitial nephritis, to make a positive diagnosis, but 
careful and persistent microscopic examination of the 
urinary sediment will usually reveal epithelial cells from 
the secreting parts of the kidneys, which are pathogno- 
monic of commencing interstitial nephritis. There is but 
one layer in these cells, and when desquamated they are 
never replaced, their position afterwards being occupied 
by endothelium, which is rarely thrown off, and is conse- 
quently not found in the urinary deposit. The microscope 
must be the main dependence for early diagnostic recog- 
nition. In contracted kidney following parenchymatous 
nephritis, there is an abundance of albumen, and casts are 
numerous; dropsy is well marked. Cardiac hypertrophy 
may be present ; if it is, the urine will be abundant and 
the dropsy slight. In interstitial nephritis cardiac hyper- 
trophy is marked ; casts are few in number, usually of the 
hyalin or light granular variety ; dropsy is absent ; urine 
abundant, albumen absent, or insignificant in amount. 

In the large white kidney, the urine daily secreted is 
less than normal, the specific gravity is possibly increased, 
albumen is abundant, and the dropsy marked. There is 
no enlargement of the heart. 
15 



226 TJROPOIETIC DISEASES. 

Prognosis. — Unfavorable for recovery, but favorable as 
regards the prolongation of life, provided the amount of 
tissue involved is limited; the progress of the disease is 
dependent greatly upon the hygiene and mode of life. 
When compensatory hypertrophy gives place to dilatation 
the end is not far off. 

Treatment. — Arsenicum album is indicated in interstitial 
nephritis of malarial origin, or in the productive nephritis 
following scarlet fever, with hypertrophy of the left ven- 
tricle; cardiac asthma, aggravated on lying down, the 
paroxysms occurring especially about midnight ; tingling 
in the fingers, particularly of the left hand ; restlessness, 
anxiety, thirst for small quantities of water, which may be 
immediately rejected ; rapid sinking of the vital forces. 

Aurum muriaticum : Urine clear, copious, slightly albu- 
minous, with few casts ; cardiac palpitation, pressing pain 
or feeling of heat in the lumbar region, extending to the 
bladder, and down the sides; over-sensitiveness to pain; 
hypochondriac, quarrelsome, general weakness, with gas- 
tric and hepatic disturbances. 

Glonoine: Polyuria, urine of low specific gravity, vio- 
lent heart action, great arterial tension, painless throbbing 
in all parts of the body, face bright red, puffy, cerebral 
hyperemia, pain in head aggravated by motion, relieved by 
external pressure. This remedy has given great relief in 
arterial tension, uraemic headaches and cardiac asthma ; it 
also reduces the quantity of urine secreted. 

Kali iodatum : When due to syphilis this remedy acts 
well. The symptomatic indications are darting pains in the 
kidney region, burning pains in the lumbar region with 
difficulty in walking, urine clear and copious, especially at 
night, urea diminished. 

Lithium carbonicum and benzoicum have been of much 
benefit when the nephritis was of gouty origin. 

Mercurius dulcis : This preparation of mercury seems 



INTERSTITIAL NEPHRITIS. 227 

especially adapted to interstitial nephritis, and is the form 
in which it should be administered when indicated. 

Nitric acidum : Interstitial nephritis with copious, pale 
urine of low specific gravity, and general symptoms of 
atonic gout. It is characterized by great weakness and 
prostration, especially in the morning, with pains of a 
pressing character in the lumbar region. 

Nux vomica: Interstitial nephritis with gastric disturb- 
ances. Polyurea, nausea, vomiting, and the mental char- 
acteristics of this remedy. 

Plumbum metallicum : Marked tendency to ursemic con- 
vulsions, uric acid diminished, clonic spasms of the muscles 
of the face and extremities, dropsy slight, urine slightly 
albuminous, mental depression, amaurosis, etc. For other 
remedies with their symptomatic indications, see chapter 
on renal therapeutics. 

When the disease is recognized early — that is, before 
extensive interstitial contraction of the kidney tissue has 
taken place, with its compensatory hypertrophy of the 
heart — life can be prolonged, and possibly a cure may 
ensue when the patients have a good general constitution 
and family history, but much depends upon the medical 
and hygienic advice and the manner in which it is fol- 
lowed. After contraction of the kidney tissue has taken 
place, palliation only with prolongation of life can be 
promised or reasonably expected. If the patient is ob- 
liged to reside in the temperate regions, is worried by 
the anxieties of active business life, or indulges in ex- 
cessive manual labor, relief cannot consistently be antici- 
pated. A dry, equable climate is to be advised, and in 
many cases a sojourn in the southern climates during the 
winter months to avoid as much as possible sudden atmos- 
pheric changes. If this change is impossible, and out-door 
exercise is allowed, the patient should be confined to the 
house or possibly remain in bed when the weather is in- 



228 UROPOIETIC DISEASES. 

clement. Experience has demonstrated that the quantity 
of albumen is reduced or entirely disappears from Brightic 
urine, when, from any cause, the patient is confined to the 
bed ; hence the advisability of remaining in bed until the 
albumen disappears ; and if any future time it returns the 
bed treatment should be repeated. 

Dry, hilly regions, when warm, are more favorable than 
the mountains or seaside, but the mistaken idea of sending 
a patient in the last stage of any disease to a health resort 
is unadvisable and cruel in the extreme ; it removes 
him from his family, deprives him of the usual com- 
forts of life, and substitutes an unsatisfactory and unpalat- 
able dietary, with possibly poor hygiene, and is sure to 
hasten rather than postpone the end. But when climatic 
changes are properly selected, there is no doubt they have 
much influence in retarding the progress of the disease. 

The patient should be properly and seasonably clothed ; 
silk or woolen undergarments should be worn at all times. 
Hot air and steam baths are beneficial, but when the gen- 
eral cardiac tone is below the normal, they must not be 
used sufficiently to weaken the patient. The hot wet 
pack is often of benefit, but cold baths and sea bathing 
must always be prohibited. Sponge baths, followed by 
brisk friction, twice a week, are to be recommended. Men- 
tal and physical fatigue, anxiety and worry, as well as every- 
thing that accelerates the action of the heart, increase the 
severity of the symptoms. The heart tone must be main- 
tained at all times, yet not over-stimulated, or headache, 
cerebral hemorrhages, epistaxis, etc., will result. 

The diet must be nutritious, but not so nitrogenous as 
to increase the work of the already damaged kidney. The 
classical diet is undoubtedly milk, as it also has the power of 
reducing the quantity of albumen and increasing the quan- 
tity of urea excreted. Some patients thrive on a milk diet, 
while others are unable to take it for any length of time. 



AMYLOID NEPHRITIS. 229 

When large quantities of milk are daily ingested, say, two 
to four quarts, it can be varied somewhat by adding a little 
salt, or flavoring it with some palatable extract ; it can be 
peptonized, or taken in the form of a milk lemonade after 
being peptonized ; it may be mixed with vichy or lime 
water, or be modified as kumyss, matzoon, ice cream, etc. 
When the plain milk diet causes muscular fatigue, the 
addition of a little farinaceous food may be necessary. 
When this occurs, or there are indications of its approach, 
the animal food must be increased. The ingestion of the 
fatty food must be encouraged. Those who cannot tolerate 
the milk diet sometimes do very well on animal broths, fish 
(salmon and lobsters excepted), veal and lamb, chicken, 
fowls in general, game and vegetables; eggs, as a rule, 
should be avoided, and sugars and starches restricted. 
Some do well on a general mixed diet, but after all, each 
case is an entity by itself. When headache, nausea, etc., 
announce the approach of ursemic conditions, the nitroge- 
nous food must be reduced. When animal diet is neces- 
sary, the white meat is less objectionable than the red. 

If the interstitial nephritis is the result of the syphilis, 
some of the anti-syphilitic remedies will be required, i. <?., 
Mercury, Potassium iodide, etc.; if of a gouty origin, 
Colchicum. The dyspnoea will require Nitro-glycerine or 
Chloral hydrate to dilate the arteries and control the heart. 

AMYLOID NEPHRITIS. 

Lardaceous or Waxy Kidney, Depurative Infiltration of 
the Kidney, etc. 

Etiology. — This variety of kidney disease is always 
dependent upon some constitutional disorder, and its 
course will depend upon the original condition. It is fre- 
quently the result of chronic suppuration and ulceration, 
as in the third stage of phthisis pulmonalis; ulceration 
and necrosis of the bony tissue; Pott's disease; chronic 



230 UROPOIETIC DISEASES. 

ulcers of the leg, and the tertiary stage of syphilis. In 
lues it usually exists as a waxy infiltration of a con- 
tracted kidney. When it arises from other than a 
syphilitic infection there is no associated renal contraction. 
The waxy infiltration is due to some chemical change in the 
constituents of the blood. The infiltration appears first as 
small deposits in the minute vessels of the kidneys and 
other organs. It develops frequently between the twentieth 
and fiftieth year of life, and more often in the male than 
the female. 

Pathological Anatomy. — The lesions which exist in 
this form of nephritis are the same as those present in 
chronic parenchymatous nephritis with exudation, with 
the addition that the walls of the capillaries in the tufts of 
the glomeruli undergo amyloid degeneration. The cells 
covering the capillaries are swollen and increased in 
number. 

Clinical History. — Amyloid changes in the kidneys 
develop simultaneously with like lesions in the liver, 
spleen, intestines, thyroid gland, etc. The distinctive 
clinical history of amyloid nephritis is somewhat marked. 
It rarely occurs alone, but is associated with parenchy- 
matous and occasionally with interstitial nephritis. In 
the early stage, the quantity of urine daily excreted may 
be about normal, occasionally a little below the average. 
The amount of albumen voided is small and not 
persistent. The disease develops slowly, the subject 
becomes emaciated, the urine gradually increases in quan- 
tity, and sometimes reaches, in a well-pronounced case, 
one hundred ounces per day ; the specific gravity ranges 
from 1003 to 1012, and the albumen becomes abundant. 
The urinary sediment is slight, and casts are infrequent ; 
when present they are of the hyaline variety, with an 
occasional one of the large waxy class which gives the 
characteristic reaction with iodine. Sometimes, red and 



AMYLOID NEPHRITIS. 231 

white blood corpuscles may be present. If a decided 
parenchymatous nephritis is associated with this condi- 
tion, the quantity of urine excreted will be less and the 
casts will be more numerous and of greater variety. There 
are no associated cardiac lesions, hence no hemorrhages, 
headaches, dyspnoea, etc. 

Dropsy is usually present. It is persistent, and appears 
particularly in, or may be confined to, the lower extrem- 
ities and abdomen. The dropsy, with the increased quan- 
tity of urine, is characteristic of amyloid nephritis, and is 
usually accompanied by diarrhoea of an intractable 
character. Vomiting may also occur. Ursemic symptoms 
are rare. The anaemia is due more to the general dys- 
crasia than to any special lesion of the kidney. 

Diagnosis. — When amyloid nephritis is associated with, 
or engrafted upon, some other kidney disease, it is almost, 
if not quite, impossible to make a positive diagnosis until 
the autopsy, and the lesion is confirmed by the character- 
istic chemical reaction of the tissues, in uncomplicated 
cases the diagnosis depends upon the large amount of urine 
of low specific gravity, the accompanying dropsy and 
diarrhoea, with the absence of cardiac hypertrophy and 
ursemic symptoms. 

Prognosis. — As this disease is a sequela of, and depend- 
ent upon, other diseased conditions of the system, and 
shows itself in other organs at the same time, it may be 
looked upon as progressively fatal, although many years 
may elapse before death occurs. 

Treatment. — Kali iodide will be required for amyloid 
nephritis of specific origin, accompanied by darting pains 
in the renal region, or a feeling as if the back was being 
squeezed in a vise ; urine clear, copious, especially at night. 

Ivycopodium is very frequently indicated. The char- 
acteristic digestive symptoms are usually prominent, due to 
the amyloid involvement of the mucous membrane of the 



232 UROPOIETIC DISEASES. 

stomach and intestines. All symptoms are worse from 4 
to 8 P. M. 

Nitric acidum : Great weakness, pressing pains in lumbar 
region, gastric disturbances, fetid breath, and obstinate 
diarrhoea. 

Phosphoric acidum : Mental indifference, pain in back, 
nutritive disturbances ; also indicated for the hectic and 
evidences of suppuration in other parts of the body, with 
which this disease is so frequently accompanied. For 
other remedies, see chapter on renal therapeutics. 

The general treatment will vary with the cause of the 
disease. A generous diet is always indicated. 



CHAPTER XVIII. 

CYSTIC DEGENERATION OF THE KIDNEY. 

Etiology. — This condition may be congenital or ac- 
quired. When congenital it usually produces death before 
the end of the first year. Virchow considers it due to im- 
perforate uriniferous tubes. Death may occur in utero, 
though occasionally life is prolonged to advanced years. 
In the adult, it is frequently associated with chronic inter- 
stitial nephritis; sometimes it happens, without apparent 
cause, between the fortieth and sixtieth year, usually ac- 
companied with similar change in the liver and bronzing 
of the skin. Cystic degeneration of the kidneys is divided 
into five varieties : (a) cysts associated with chronic inter- 
stitial nephritis ; (b) general cystic disease without asso- 
ciated nephritis ; (c) simple, solitary cysts ; (d) hydatids ; 
(e) dermoid cysts. 

Dermoid cysts of the kidney have never been demon- 
strated in a human being. 

Pathological Anatomy. — In the congenital form both 
kidneys are very much enlarged, the left being usually 
considerably more so than the right. The whole organ is 
an unshapely, irregular mass of cysts, which are closely 
crowded together and separated by connective tissue. 
In some places renal tissue, which microscopically may 
appear normal or characteristic of a chronic interstitial 
nephritis, separates the cysts. Each cyst is made up of a 
fibrous capsule varying in thickness, lined with flat epithe- 
lium, containing a light yellow fluid, in which urea and 
the salts normal to the urine are present. 

In the acquired form, cysts, varying in size from a pin- 



234 UROPOIETIC DISEASES. 

head to a large bean are occasionally present throughout 
the cortical portion, between the pyramids, or on the sur- 
face immediately beneath the capsule, in otherwise normal 
kidneys. The cysts cause the surface of the kidney to 
bulge, and at times give it the appearance of being 
tabulated. The kidney tissue surrounding them may be 
compressed, and some of the more approximate tubules 
obliterated. They have a thin connective tissue cap- 
sule, are lined with flattened epiihelium, and contain a 
thin watery fluid. 

In the atrophied kidneys of chronic parenchymatous 
nephritis without exudation, some of the tubules are 
dilated to such an extent as to form cysts. These are 
seldom very large, but may attain a size visible to the 
naked eye. 

Clinical History. — This is obscure, the autopsy often 
shows marked cystic degeneration of the kidney, when the 
condition was not suspected during life. There is usually 
pain in the lumbar region, and occasional hsematuria. Ar- 
terial tension and cardiac hypertrophy are generally absent. 
Dropsical conditions sometimes appear, but they cannot 
be differentiated from those occurring in chronic intersti- 
tial, nephritis. Occasionally, on examination of the renal 
region by palpation, the enlarged kidney can be discov- 
ered and sometimes differentiated. Death occurs, as in in- 
terstitial nephritis, from cerebral haemorrhage, suppression 
of the urine or uraemia, the latter being the most fre- 
quent termination. 

HYDATIDS OE THE KIDNEY. 

Etiology. — This condition is rare in America, although 
frequent in Iceland and Australia. It occurs more often 
in the male, owing probably to his more intimate associa- 
tion with dogs. About one-fifth of all hydatid cysts found 
in the human body develop in the kidney. 




CONGENITA!, CYSTIC DEGENERATION OF THE KIDNEY. 



From a specimen in the museum of the Metropolitan Hospital, New York 
(Photograph oue-thircl size.) 



HYDATIDS OF THE KIDNEY. 235 

Pathological Anatomy. — As a rule, hydatid cysts de- 
velop in the parenchyma, but they may be located between 
the capsule and the cortex. The left kidney is more 
often involved than the right. Inflammation, with adhe- 
sions between the sac and a neighboring part, sometimes 
occurs, and rupture follows. If the rupture takes place 
into one of the natural outlets of the body recovery may 
ensue, but if into a closed cavity death will result. 
Hydatids may degenerate into calcareous masses, consisting 
of phosphate of lime, cholesterin and fats. 

Small hydatid cysts may rupture into the urinary tract 
and be discharged with the urine, without their existence 
having been suspected. In some cases they become so 
large that they interfere with the functions of the kidney 
and encroach upon the neighboring organs, and their dis- 
covery becomes proportionately easy. It is said that they 
can be recognized by their characteristic fremitus on 
manipulation, but the proper method is to aspirate and 
examine the cystic fluid for the booklets. However, the 
simple puncture of the sac for diagnostic purposes has re- 
sulted in death, due to the escape of the poisonous contents 
of the cyst into the puncture tract. 

Treatment. — For remedies, see interstitial nephritis and 
chapter on therapeutics. If one kidney only is involved 
and a cystic condition can be positively diagnosed, a 
nephrotomy, with proper drainage, may be made ; some- 
times the size of the cyst may necessitate a partial or com- 
plete nephrectomy ; otherwise the treatment must be on 
the same general principles advised for chronic interstitial 
nephritis. If the cyst is of a hydatid variety, either a 
nephrotomy with permanent drainage, enucleation of the 
cyst, or a nephrectomy will be indicated. 



CHAPTER XIX. 

RENAL TUBERCULOSIS. 

Etiology. — When it is primary, the condition may in- 
volve in its early stage one kidney only. When secondary 
to a tubercular condition of the lungs, intestines, lym- 
phatic glands, bladder, prostate, seminal vesicles, testes, 
labia, fallopian tubes, ovaries, or developing in course of a 
general tuberculosis, it is usually bilateral. There are 
three forms of renal tuberculosis : The descending form, 
where the disease commences in the kidney and is usually 
uni-lateral ; the ascending form, in which some of the sub- 
renal tissues are first invaded, usually bi-lateral ; and a 
third form, in which the whole genito-urinary tract is 
simultaneously involved. 

The one direct cause of renal tuberculosis is the pres- 
ence in the tissues of the tubercular bacilli and their 
ptomaines. The predisposing cause is some inherited or 
acquired weakness of the kidney. As a primary affection 
it is of much interest, but when viewed in the course of 
a general systematic tubercular condition, it is not charac- 
teristic or of great importance. It is a disease essentially 
of early middle adult life, yet it has developed as early as 
the third month, and as late as the seventy-second year. 
It appears nearly twice as frequently in the male as in the 
female, and it occurs in about 4 per cent, of all cases of 
general or local tuberculosis. When primary it is thought 
by some to be due to direct infection during the act of 
copulation, especially when the disease has extended 
through the genito-urinary tract, though its origin is prob- 
ably hsematogenous. 



RENAL TUBERCULOSIS. 237 

Pathological Anatomy. — When the condition is a part 
of a general miliary tuberculosis, the kidney tissue and 
the surface of the organ are studded with miliary tuber- 
cles. The structure surrounding the tubules undergoes 
no material change. Both kidneys are usually affected. 
When the tubercular infection of the organ is primary or 
when due to the extension of a pre-existing tubercular 
lesion in some neighboring urinary organ, the pathologi- 
cal condition, in each instance, is the same, but, as a rule, 
one kidney only is affected, and the left more frequently 
than the right. 

The inflammation generally begins in the mucous mem- 
brane of the pelvis, gradually extends into the pyramids 
and the cortex, finally involving a greater part or the 
whole of the kidney. The formation of tubercle tissue 
begins in the stroma. The epithelial lining of the neigh- 
boring tubules proliferates and subsequently becomes ne- 
crotic. The affected areas undergo cheesy degeneration 
with the formation of cavities, varying in size and 
number, according to the extent of the lesion, and contain 
a cheesy mass, in the substance of which tubercular bacilli 
are usually present. 

The portions of the kidney not affected by the tuber- 
cular inflammation are very apt to undergo an interstitial 
inflammation of the chronic type. Sometimes the disease 
is self-limited, and the areas of cheesy degeneration become 
infiltrated with the salts of lime. 

Clinical History. — Primary tuberculosis of the kidney 
is rarely discovered before associated involvement of the 
genitourinary apparatus occurs. When the parenchyma 
of the organ only is involved, there are no symptoms ; 
pain, etc., develop simultaneously with the involve- 
ment of the mucous membrane, or with the rupture 
of a tubercular abscess into the pelvis of the kidney. 
Sometimes at the first examinations the diseased kidney 



238 UROPOIETIC DISEASES. 

can be distinguished as a tumor on the affected side. 
There is soreness, referred to the lumbar region, with an 
occasional lancinating or burning pain extending down 
the groin into the testes or labia, aggravated during 
micturition. This pain may be increased by motion, and 
some patients, to lessen it, fix the parts to keep them quiet 
thereby acquiring an apparent lateral curvature of the spine* 
As the pelvis of the kidney and the ureteral opening at the 
bladder are invaded, micturition becomes more frequent 
and distressing. The urine at first may be increased in 
quantity, but in other respects it is apparently normal ; 
when the bladder becomes to some degree involved, or a 
pyonephrosis develops, it may become alkaline, and con- 
tain tubercle bacilli, small cheesy masses, pus, albumen, 
and occasionally a little blood. Heematuria, however, is 
not a constant symptom, as it is in cancer of the kidney, 
though Pousson, Jour, de Med. de Bordeaux, 1895, reports 
a case of primary renal tuberculosis in which there was 
profuse and long-continued hemorrhage without other 
change in the character of the urine. The quantity of 
blood voided with the urine is not influenced by exercise. 
If the tubercles at any point in the kidney rupture and 
discharge the presence in the urine of the bacilli with pus, 
blood corpuscles, fibrinous shreds, etc., will establish the 
diagnosis. Renal casts are sometimes present, but they 
are unimportant. If the disease is confined to one kid- 
ney, a cheesy mass may plug its ureter and stop the flow 
of abnormal urine ; and the urine voided by and coming 
from the healthy kidney will be clear and normal. In all 
obscure urinary diseases, especially when primary tubercu- 
losis of the kidney is suspected, a cystoscopic examination of 
the bladder should be made and the ureters catheterized. 
The diagnostic indications as revealed by the cystocope are 
as follows : The mucous membrane surrounding the ureteral 
opening is congested, and may have the appearance of 



RENAL TUBERCULOSIS. 239 

footprints in snow. If the urine flowing from the ureteral 
catheter contains tubercular bacilli, and the ureter and 
urine of the opposite kidney are normal, local tuberculosis 
may be positively diagnosticated. 

Mucus in the urine, with frequent micturition in child- 
hood, is often the forerunner of renal tuberculosis, and 
when accompanied by painful urination has been mis- 
taken for stone in the bladder. When the symptoms 
simulate stone in the bladder, the rise of temperature, 
which occurs in tuberculosis, will differentiate the two 
conditions. Frequent micturition, accompanied with uri- 
nary incontinence, without apparent cause, should always 
excite apprehension of a tubercular involvement of the 
kidney, especially if there is a tubercular family history. 
As the disease progresses, emaciation, hectic fever, loss of 
strength and general systemic involvement, with diarrhoea 
and vomiting, occur. The disease is usually fatal, al- 
though in some cases life may be prolonged for years ; a 
few apparent recoveries have been reported. 

In secondary tubercular involvement of the kidney the 
symptoms are unimportant, though pain and soreness, re- 
ferred to the lumbar region, with albuminous urine, should 
suggest a guarded prognosis. If tubercular bacilli are 
found in the urine, the case must be considered hopeless. 

Treatment. — Arsenicum iod., Calcarea iod., Kali iod., 
Hekla lava, Chininum ars., Chininum sulph., Calcarea 
hypophos., Calcarea carb., Nux vomica, Nitric acid, Nitro- 
muriatic acid and Kreosotum must be prescribed as indi- 
cated by their general symptomatology (see indications in 
chapter on renal therapeutics). Bacillinum, 200 , a dose 
once a week should also be tried. 

Change of air and surroundings, with general hygiene 
or a sea-voyage, will be beneficial when the urinary symp- 
toms will allow. In the early stage of primary renal tuber- 
culosis, much may be expected from a change of climate. 



240 UROPOIETIC DISEASES. 

One which is dry and equable should be selected. High 
altitudes with too cold an atmosphere are rarely bene- 
ficial, as cold is particularly unsuited to patients suffering 
from tuberculous, since chilling the surface greatly in- 
creases the kidney lesion ; hot, dry climates have the dis- 
advantage of causing concentrated urine, which distinctly 
increases the bladder irritability. A nephrotomy with 
proper drainage of the tubercular pus cavity is sometimes 
beneficial, and removal of the diseased kidney may be in- 
dicated when a cystoscopic examination of the bladder and 
catheterization of the ureters demonstrate the healthy con- 
dition of the other kidney and a urinalysis shows that the 
quantity of urea voided daily is not less than one-third the 
normal. The immediate results of this operation are often 
brilliant, both as to immediate relief of the suffering and 
prolongation of life; in some a cure may be hoped for, 
Fraeklam reports a perfect cure in over 40 per cent, of 
eighty primary nephrectomies. Usually the diagnosis can- 
not be made sufficiently early for the operation to be of any 
permanent benefit. The frequent and painful micturition 
in some of the more chronic cases may require for its relief 
a cystotomy for drainage. 



CHAPTER XX. 
RENAL SYPHILIS. 

ACUTE SYPHILITIC NEPHRITIS. 

Etiology. — This manifestation of syphilis frequently de- 
velops early in the secondary stage, i. <?., eight to twelve 
weeks after the original chancre. Albuminuria occurs in 
about 4 per cent, of all syphilitics. 

Pathological Anatomy. — The uriniferous tubules are 
congested and the gross appearance of the kidney is very 
similar to that of exudative nephritis occurring after scarlet 
fever. 

Clinical History. — Micturition becomes frequent, the 
urine is reduced in quantity and contains albumen, blood, 
epithelial, hyaline and granular casts. CEdema may be 
general or amount only to a slight pufnness under the 
eyes. Headache and slight digestive disturbances are 
common. 

Prognosis. — Resolution is rapid. 

Treatment. — Mercurius corrosivus generally covers the 
totality of the symptoms. The general care is that ad- 
vised for acute parenchymatous nephritis. 

CHRONIC SYPHILITIC NEPHRITIS. 

Etiology. — In the later stages of syphilis, interstitial 
hyperplasia, gummata and amyloid degeneration often de- 
velop without special symptoms except the presence of 
albumen and casts in the urine. 

Pathological Anatomy. — The kidney may show amy- 
loid degeneration, interstitial inflammation, or developing 
16 



242 UROPOIETIC DISEASES. 

gumrnata; the three conditions are frequently associated^ 
the amyloid predominating. 

Clinical History. — The symptoms vary little, if any, 
from those of chronic nephritis. As the disease advances 
and the gummatous growths break down, the urine be- 
comes turbid, of a dirty brown color, contains albumen, a 
large quantity of detritus, with blood and epithelial cylin- 
ders. 

Treatment. — Good results may follow anti-syphilitic 
treatment, with a milk or mixed diet, in connection with 
good hours and hygiene. 



CHAPTER XXI. 
RENAL TUMORS. 

New growths in the kidneys may be congenital or ac- 
quired. The congenital comprise simple and dermoid 
cysts, hydronephrotic conditions, cavernous tumors, which 
give no recognized symptoms and are little understood, 
and the sarcomata. 

The acquired are naturally divided into the extra-renal, 
pelvic, capsular, and glandular varieties. Extra-renal 
tumors include perinephritis, extra-renal cysts, which are 
sometimes only discovered at the autopsy, having given 
no clinical evidence of their presence. Myxolipomatous 
tumors which sometimes develop in the perirenal tissue, 
and attain considerable size. In malignant renal growths, 
it is sometimes impossible to differentiate the intra- from 
those of extra-renal origin. 

The pelvic variety includes hydro- and pyonephrosis, 
tubercular pyelitis, sarcomata and carcinomata. Villous 
growths are rare, but when they do occur they may be- 
come of an enormous size. The glandular and capsular 
varieties include simple, hydatid and dermoid cysts, tuber- 
cular growths, and syphilitic gummata, which may be 
recognized by the specific history, and the relief produced 
by anti-syphilitic treatment. L,ymphadenomatous growths 
are uncommon ; they sometimes accompany Hodgkins' 
disease. Endotbeliomata are also rare ; the history of two 
cases, with their pathological specimens, were presented to 
the N. Y. Pathological Society, April 8, 1896, by Dr. G. 
A. Tuttle. In one case there was pain, dragging in char- 
acter, in the right groin, extending into the testicle ; uri- 



244 UROPOIETIC DISEASES. 

nation was scanty, with frequent night sweats. The tumor 
was the size of a cocoanut, occupied the right renal region, 
and was successfully removed. A number of small inno- 
cent growths sometimes develop, but as they present no 
clinical symptoms they cannot be distinguished during 
life. 

The symptoms of renal growths are not definite or con- 
stant — in fact, they are considered the most difficult of 
all abdominal tumors to differentiate. They develop more 
frequently in childhood and after the fortieth year. 

BENIGN GROWTHS OF THE KIDNEY. 

The following benign growths are occasionally found in 
the kidney: Lipomata, fibromata, myomata, angiomata, 
papillomata. They are, as a rule, small, and give no clinical 
evidence of their presence. They are often discovered at 
autopsies, when no lesion of the kidneys has been suspected. 

Adenomata may be villous or alveolar in type. They 
vary in size, some being as small as a pea, and others of 
large size. Delafield and Prudden describe a papillary 
adenoma, which involves the whole of the organ, and is 
malignant. 

MALIGNANT GROWTHS OF THE KIDNEY. 

Etiology. — No known, absolute or undoubted cause 
exists. Sarcoma is especially a disease of childhood, 
and usually develops before the eighth year. From this 
period until late in adult life malignant disease of the kid- 
neys is rare, but when it does occur it is generally carci- 
nomatous or of the medullary type. In nearly all cases 
there is a history of a fall, blow or strain, generally re- 
ferred to the renal region. Malignant growths may be 
either carcinomatous or sarcomatous. In many respects 
they present similar symptoms, and may, therefore, be 
described together and their special points of difference 
noted. 



MALIGNANT GROWTHS OF THE KIDNEY. 245 

Carcinomata are rare. They were once considered to 
be the most common malignant tumors of the kidney, but 
it is now generally admitted that many of the tumors 
which had been described as carcinomata were, in reality, 
sarcomata. It is often difficult to differentiate the two. 
When a true carcinoma is found in the kidney it is gen- 
erally metastatic. 

McNeeney, in the British Medical Journal, February 
8, 1896, describes two renal tumors, whose structure bears 
a resemblance to that of suprarenal tissue. He is disposed 
to class them with the carcinomata. 

Sarcomata are by far the most common malignant 
growths originating in the renal tissue. They may be of 
the round or spindle-celled variety. Several mixed types 
are described, i. e., liposarcoma, myosarcoma, myxosar- 
coma. They are apt to originate in the pelvis of the 
kidney. They may develop outside the kidney, and later 
involve the organ by peripheral growth ; sometimes they 
originate in the parenchyma or< in the pelvis. Sarcomata 
are prone to grow to large size. Jacobi reported one 
weighing thirty-six pounds. They are soft and often 
break down, giving rise to hemorrhage of greater or less 
severity within their substance. Pressure of the tumor on 
the ureter may produce hydronephrosis. Thrombosis of 
the inferior vena cava may occur from the same cause. 
They happen in one kidney about as often as in the other, 
but rarely in both at the same time. 

Clinical History. — From three-tenths to one per cent, 
of all malignant growths occurring in the human body 
originate in the kidney. When the disease is primary 
usually one kidney only is involved, while in the secondary 
form both are equally diseased. The growth may extend 
upward, involving the spleen and lungs or liver and lungs, 
interfering with respiration, or downward into the iliac 
region of the diseased side and forward into the epigastric 



246 UROPOIETIC DISEASES. 

region. The size of the tumor can be approximately 
denned and distinguished by placing the fingers of one 
hand along the lower ribs behind and external to the 
larger muscles of the back, and the fingers of the other 
hand below the ribs in front, then on deep expiration, 
especially in a thin subject, the change in size of the kid- 
ney can be easily ascertained. It is usually immovably 
attached to the neighboring parts and on percussion there 
may be tympanitic resonance in front when it is covered 
by the colon. 

Pain in the diseased kidney is quite a constant symptom, 
though frequently absent in sarcoma ; it is usually spoken 
of as a continuous dull soreness, not especially affected by 
motion or position, and does not shoot into the neighboring 
parts, down the groin, into the testicles or labia. The 
tumor is usually somewhat sore to touch. 

The urine may at all times be normal, especially if the 
growth has developed external to the kidney; but as the 
parenchyma of the kidney becomes involved hsematuria 
will appear ; it may be slight and transitory or continuous 
and profuse. When continued and considerable in amount, 
marked anaemia develops, the urine will have the color 
and frequently contain small clots of blood. The hemor- 
rhage is not affected by motion, position, or time of day, 
as it is when it results from calculi in the pelvis of the kid- 
ney. About one-half of all cases of malignant disease of the 
kidney have a history of frequent or constant hsematuria. 
The genital organs are seldom involved, while other organs 
rarely escape secondary involvement. As the disease 
advances the cancerous cachexia, emaciation, constipation 
or alternate constipation and diarrhoea, loss of appetite, etc., 
become more pronounced, and death finally ensues. 

Prognosis. — Death has occurred as early as the ninth 
week ; some patients have lived for a period of three to fif- 
teen years, and others, after operation, have apparently re- 



MALIGNANT GROWTHS OF THE KIDNEY. 247 

covered, only to die ultimately. Patients with carcinornata 
may live from three to fifteen years ; those with sarcomata 
two or three years, and those with epitheliomata between 
two and fifteen years. 

Treatment. — Arsenicum alb. is frequently indicated 
and gives more relief than any known remedy. The 
hsematuria may require Ferrum, Millefolium, Hamamelis 
virg., Secale, Ipecacuanha or Brigeron. The general 
building up of the system by nutritious and easily-digested 
food must receive attention. When the cancerous con- 
dition is recognized early, and it is uni-lateral, the diseased 
kidney must be removed at once. The percentage of 
deaths from nephrotomy is about 25 per cent, but many 
cases have apparently obtained through it relief ,and even 
a cure. 



CHAPTER XXII. 
RENAL CALCULI. 

Etiology. — Renal calculi may be caused by an excess of 
the solid matters of the urine, or by the deposit of certain 
inorganic salts, the products of inflammatory conditions. 
In the first class are uric acid, the urates, oxalate of lime> 
carbonate of lime, cystine, etc.; in the second, ammoniaco- 
magnesian phosphates and phosphate of lime. 

The urates, oxalates, phosphates, etc., are the result of 
over-concentration of the urine from dyspepsia, the in- 
gestion of sweet wines, malted liquors, over-indulgence at 
the table with lack of exercise, an over-acid condition of 
the system, lithaemia, etc. In many, starch, sugar, or a 
diet of fatty food tends to the over-production of solid 
matter in the urine. The absence of salt in the food pre- 
disposes to this state, i. <?., salt makes the uric acid more 
solvent; it also increases thirst, and insures a better daily 
flushing of the kidneys. Sexual disorders favor this con- 
dition, and age seems to have a special predilection. The 
statistics of Sir Henry Thompson show that in 1,827 
operations performed by him for the removal of kidney 
stone, 1,158 were on patients under twenty-five years; 
1,001 under fifteen years of age ; from twenty-five to 
thirty-five, there were 231 cases; and from twenty-five to 
fifty-five, 303 cases, thus placing their greatest frequency 
of occurrence during the period of adolescence, undoubt- 
edly engendered by the marked acid state of the urine, 
as well as the frequent feverish conditions and low vi- 
tality so common at this period of life. Cadge has 
stated that the prevalence of renal stone in children is due 



RENAL CALCULI. 249 

to improper diet and an insufficient quantity of milk, that 
it will prevail in proportion as solid or artificial foods are 
ingested. In youth, the calculi are largely composed 
of uric acid and urates ; in middle life, of oxalate of lime ; 
while in advanced life they are composed largely of am- 
moniaco-magnesian phosphates. 

The condition of the drinking water of the neighbor- 
hood has a decided influence in the frequency of develop- 
ment of renal calculi. Hard water has a tendency to 
increase their occurrence; and in neighborhoods where 
renal stone seems to be endemic, a change in the drinking 
water has resulted in a diminution of the number. 
Atmospheric conditions, the quality of the soil and sub-soil, 
etc., have no special influence in their production. As the 
female sex is less liable to exposure, etc., they are said to 
be proportionately less liable to renal calculi. 

Clinical History. — Renal calculi vary from microscopic 
specimens to stones of considerable size. They may be 
round, smooth, rough or irregular, consist of one primary 
element, as, uric acid, oxalate of lime ; composed of two or 
more primary elements, or made up of layers of many or 
all of the primary elements. Uric acid calculi are the 
most common. They may be yellow, brown or black, 
varying greatly in size, and present a rounded, smooth, 
or facetted surface. When fractured the sections have a 
crystalline appearance, and may appear laminated. Calculi 
of the oxalate of lime variety are less frequent, and are 
usually of a dark-brown color ; the surfaces are hard and 
rough, but may be smooth and small ; oxalate of lime is 
frequently associated with uric-acid in the formation of 
stone. Cystin calculi are yellow in color, changing to 
green on exposure. They are translucent, and on section 
give some degree of radiation in structure. Xanthin cal- 
culi have the color of cinnamon. Indigo calculi are bluish- 
black in color; one was found by Ord, in the substance of 



250 UROPOIETIC DISEASES. 

a sarcomatous kidney. Phosphate of lime calculi are 
whitish, chalky, and vary in size. Carbonate of lime cal- 
culi are yellowish, gray or brown, hard and smooth. 
Sodium urates form soft and small calculi. Urosteaiith 
consists of cholesterin, fat and uric acid, and is soft and 
greasy to the touch. 

The formation of renal calculi is believed to be due to 
the presence of a colloid substance in the urine, which 
cements the molecules of the salts together. Reindfleisch 
says that the epithelial cells which line the straight tubes 
generate a colloid material in their protoplasm. It is well 
known that in the early history of renal calculi, before 
other symptoms are present, there may be a considerable 
increase of mucus in the urine. It has also been 
noticed that calculi are usually covered with a colloid sub- 
stance or mucus, which is difficult to remove. 

The symptoms of renal calculi vary greatly, depending 
upon their size, number, character and location. They 
may be situated beneath the capsule, imbedded in the 
cortex, in the parenchyma, in the calices of the pyramids, 
loose or encapsulated in some part of the pelvis of the 
kidney. They may give rise to the condition ordinarily 
spoken of as gravel; if expelled, they cause renal colic 
during their passage, and if retained in the kidney or its 
pelvis they frequently produce calculous pyelitis and 
death. Sometimes they produce absolutely no objective 
or subjective symptoms. 

Pain in the kidney region is the most constant symptom. 
When the calculus is situated in the cortex there is a con- 
tinuous severe fixed pain, or some uneasiness and soreness, 
referred to the renal region, aggravated by motion and re- 
lieved by reclining or sleeping on the side of the diseased 
kidney, the pain being again felt when turning to the 
opposite side. A calculus imbedded in the cortex of the 
kidney occasionally does not produce pain or any change 



RENAL CALCULI. 251 

in the character of the urine voided. When the calculi 
are loose in the pelvic cavity they cause colic, with pain 
radiating to neighboring parts, which is often accompauied 
by severe bladder symptoms ; the patient finds relief from 
the pain only by reclining and sleeping on the unaffected 
side. Within a year or so after the advent of the pelvic 
stone, pus, etc., will usually appear in the urine. When 
the calculi are situated in the medulary portion of the 
kidney, the symptoms assume somewhat the character of 
the cortical or pelvic variety, according to the location, etc. 
The pain produced by a renal calculus may resemble 
that of an attack of lumbago ; it may be present only when 
deep pressure is applied over the parts. Blood in the 
urine in variable quantities is a common symptom, pro- 
duced generally by the irritation of the mucous membrane 
of the pelvis of the kidney by the calculus. In time a 
pyelitis is established and pus appears in the urine. The 
quantity of blood is increased by motion, especially by 
carriage-riding ; the urine is acid in reaction, thus dif- 
ferentiating vesical ■ calculus, in which condition carriage- 
riding does not increase the haemorrhage and the urine is 
alkaline in reaction. However, in the chronic form of 
calculous pyelitis, the urine may be accompanied by 
uraemia or hectic fever. Acute hydronephrosis may at 
any time develop from obstruction of the ureter by a 
renal calculus. An increase in the amount of mucus and 
density of the urine, even when blood and pus are absent, 
are considered diagnostic evidence of the presence of 
renal calculi. When an abundance of microscopic cal- 
culi are discharged, it is called gravel. It pro- 
duces smarting and burning on micturition, with 
irritation and congestion of the urinary tract, pain 
and uneasiness, referred to the sacro-iliac region, which 
shoots down the course of the ureter, together with irrita- 
tion at the neck of the bladder, headache, flatulence, mal- 



252 UROPOIETIC DISEASES. 

aise, etc. An over-acid and concentrated urine alone may 
keep up a long train of symptoms and finally cause or 
terminate in pyelitis, cystitis, etc. 

Treatment. — When the urine is acid the remedy may 
be Nitro-muriatic ac, Nitric ac, Nux vom., Pulsatilla, 
Sulphur, Benzoic ac, Lycopodium, Sepia, Magnesium 
boro-citr., Quinia sulph. or Sarsaparilla, and when alkaline, 
Phosphoric ac, Phosphorus or Magnesia phos. For 
symptomatology see chapter on renal therapeutics. 

In diet, light meals must be the rule. The quantity of 
meat and cream should be decreased and the average 
amount of vegetables increased. 

Champagne, sweet and new wines, malted and spirituous 
liquors must be interdicted. Sedentary habits must be 
abandoned and out-door exercise gradually increased and 
continued. Frequent bathing should be carefully con- 
ducted ; Turkish or Russian baths are helpful. Massage 
once or twice a week and frequent rubbing with a 
rough bath towel or flesh brush are productive of much 
good. Daily massage of the affected side is of special 
benefit. Sexual hygiene is important, especially in the 
young. A pint of Piperazin water should be taken daily 
in divided doses. It is prepared as follows : 

# Piperazin giss. 

Aqua Destil., 5 v. 

M 
Sig. Tablespoonful to a pint of any mineral water. 

Imported Vichy, Ems, Carlsbad, Bedford, Stafford, Con- 
trexeville, Poland, etc., or distilled water in large quan- 
tities should be advised, and the alkaline flow of urine, 
which occurs usually about 10:30 a. m., if it discontinues, 
should be re-established and maintained. When the 
alkaline waters do not produce the desired results, thirty 
grains of Citrate of potash, well diluted with water, may be 
administered at bed time and between meals. If the cal- 



RENAL CALCULI. 253 

cuius is large, alkaline waters tend to increase its size ; 
therefore they are only indicated early in the case. An 
alkaline condition of the urine prevents the deposit of the 
solid matters in the urinary tract, while acidity facilitates 
it. Whenever the urine for any length of time remains 
acid for the entire day it indicates over-acidity and con- 
centration. These conditions may give rise to many, if 
not all, of the symptoms of gravel and neuralgia of the 
kidneys. 

Urecidin in teaspoonful doses has in some cases not only 
relieved the symptoms of, but has seemingly produced a 
disoiution of, the offending stone in the kidney. Amino- 
form in seven and one-half to fifteen grain doses has also 
acted very satisfactorily. 

Glycerine one to four ounces, varying with the weight 
of the patient, diluted in an equal amount of water, 
taken at one dose between lunch and dinner, and repeated 
two or three times in the intervals of several days, has in 
a large number of cases, by its lubricant or solvent action, 
relieved the pain and assisted in the removal of the calculi. 

If continued and careful treatment does not remove all 
the symptoms, surgical relief will be required. Before ex- 
ploratory examination or other renal operation, the ureter 
should be catherterized (by the Caspar method in the male 
and by the Kelly in the female) and a proper examination 
of the urine made. In the female, Kelly's wax-covered 
probes may be introduced into the ureter to ascertain if 
there are calculi in the ureter or pelvis of the kidney. If 
calculi are present, marked indentations will appear on 
the wax-covered end of the probe ; the soft renal tissues 
make no indentation. 



CHAPTER XXIII. 
RENAL SURGERY. 

P. Wagner, in the Chir. Beitr., Festschrift fiir Bruno 
Schmidt, warns against the too hasty removal of the kid- 
ney, as experience proves that the remaining kidney fre- 
quently does not undergo compensatory hypertrophy ; con- 
sequently, it does not do the work of both organs, and the 
patient dies from insufficient renal action. He advocates 
the following rules : Nephrorraphy for floating kidney, in- 
cluding cases of intermittent hydronephrosis due to dislo- 
cation of the kidney. Nephrolithotomy for renal calculi, 
whether in the kidney or its pelvis, in the absence of ex- 
tensive suppuration or advanced alteration of the kidney- 
substance. Nephrotomy for pyonephrosis, hydronephrosis, 
and solitary cysts of the kidney or echinococcus cysts. 
Partial resection for benign tumors, localized abscesses and 
calculus formations. This operation will probably have a 
much wider application in the future than it has at pres- 
ent. Nephrectomy may be necessary either as a primary 
or secondary operation. As a primary operation it is indi- 
cated for malignant tumors of the kidney or its capsule, in 
tuberculosis, and in abscesses which are distributed 
throughout the whole kidney ; also in injuries which have 
badly lacerated the kidney and caused uncontrollable 
haemorrhage. 

Secondary nephrectomy may become necessary in emaci- 
ated patients with suspected tuberculosis in other organs, 
in whom nephrotomy and tamponade have failed to re- 



RENAL SURGERY. 255 

lieve. In cases of abscess in which the integrity of the 
other kidney is suspected, nephrotomy is indicated ; if this 
fails, the kidney should be removed. For a similar reason, 
badly lacerated kidneys, whose arteries and veins are intact, 
should be sutured, tamponed, or in part resected, and 
nephrectomy performed as secondary operation if these 
measures do not succeed. 

There remains to be considered only pyonephrosis and 
hydronephrosis. Primary nephrectomy for these condi- 
tions deprives the body of the use of some remnants of 
active renal tissue, whose loss under certain circumstances 
may mean great danger to the patient. 

Ayer's investigations Am. Medico-Surgical Bulletin, 
Sept. 12, 1896, have shown that a hydronephrosis hardly 
ever destroys all the secretory tissue. Nephrotomy in 
such cases can do no harm, and statistics show that the re- 
sulting fistulse usually close. In cases where a fistula has 
long continued to discharge urine or pus, a secondary 
nephrectomy is to be considered. 

In all extra-peritoneal operations upon the kidneys — 
nephrorraphy, nephrotomy, nephro-lithotomy or nephrect- 
omy — the technique up to the point where the kidney is 
exposed to view is the same, and is as follows : The patient 
is carefully prepared in the usual maimer. When ansesthet- 
ization is complete, he is placed upon the operating table 
on the side opposite to the proposed operation, with a sand 
or other pillow under the ilio-costal region. This makes 
the corresponding ilio-costal region tense and prominent, 
and increases the exploratory field. The body and limbs 
are both slightly flexed, the forearms brought in front of 
the chest and the head turned to one side. The field of 
the operation is made aseptic and the exposed parts prop- 
erly protected and covered with bichloride cloths. The initial 
incision is made directly over the posterior surface of the 
affected kidney and may be vertical, transverse, a combina- 



256 UROPOIETIC DISEASES. 

tion of both, or oblique. If vertical, it is made along the 
outer border of the erector spinse muscle (about two inches 
from the spine), and extends from the lower edge of the 
twelfth rib to the crest of the ilium. Sometimes, in order 
to gain sufficient room for operating, it is necessary to con- 
tinue the incision upward and sever the lower rib. This 
should not be done if it can be avoided, as pleurisy and 
other complications sometimes result. If a transverse in- 
cision is preferred, it is made about one inch below and 
parallel with the free border of the ribs and from three to 
four inches in length. Many surgeons combine the two 
incisions, making the transverse about three inches long, 
so as to give the greatest amount of room for the removal 
of the kidney if necessary. The skin, subcutaneous con- 
nective tissue, muscles, etc., are divided, layer after layer, 
until the kidney is exposed, the bleeding points properly 
secured and ligated and the organ examined both occularly 
and carefully with the finger. The incision and sub- 
sequent steps are comparatively free from danger, although 
care must be taken not to destroy too much of the con- 
nective tissue which binds the kidney to the posterior wall 
of the abdomen. 

If no evidence of calculi or disease is found, the parts 
can be properly drained and packed with Iodoform gauze, 
or the wound can be closed without drainage, the mus- 
cular layers being approximated with fine chromized cat- 
gut, and the skin with fine silk, the dressing completed 
with bichloride gauze held in place with long strips of 
adhesive plaster, a layer of cotton and a snug binder. The 
wound will rarely require redressing until the seventh 
day. Recovery is usually rapid. Many surgeons believe 
that in the majority of cases good results follow this 
operation, owing to a better fixation of the kidney to the 
abdominal wall, even when no evidence of disease is dis- 
covered by the exploratory incision. 



RENAL SURGERY. 257 

Nephrorrhaphy. — Nephropexy was introduced by Hahn 
in 1 88 1. It is almost free from danger, the death rate 
being less than 3 per cent. After the kidney is exposed, 
as above, it is pressed into the orifice of the wound and re- 
tained there by pressure upon the anterior surface of the 
abdomen by an assistant. The edges of the wound are 
held open with retractors, the fatty capsule opened and 
the true capsule exposed. When this is accomplished, one 
of the following methods of fixation may be employed : 
(a) Sutures through the fibrous capsule, (b) Suture 
through the adipose capsule, (c) Sutures through and in- 
cluding a portion (about one-half inch wide and one-sixth 
inch thick) of the parenchyma, (d) Incising the fibrous 
capsule, stripping part of it from the kidney, and introduc- 
ing sutures through the capsule and parenchyma just in- 
side of the border of the raw surface. From four to ten 
sutures are used to attach the kidney to the incised mus- 
cular tissues ; silk, silk- worm, kangaroo tendon or chroma- 
cized catgut sutures may be used, according to the, judg- 
ment of the operator. After the sutures are introduced 
and properly tied, the operation may be completed on the 
lines of the closed or open method, and the parts dressed 
antiseptically. In this operation, it is necessasy that a 
large amount of granulation tissue should be thrown out 
to glue and attach the kidney to its place, and this is best 
favored when the capsule of the kidney is partly stripped 
off. Some operators suture the kidney to the twelfth rib, 
while others remove a portion of the lateral ligament of 
the spinal column and pass it through the parenchyma 
of the kidney, and thus anchor the movable organ to its 
place by living tissue. The passing of the ligament or 
the sutures through the parenchyma of the kidney gives 
rise to no unpleasant symptoms, except possibly a transient 
hematuria. Senn condemns the passing of sutures 
through the glandular substance of the kidney. He rec- 
17 



258 UROPOIETIC DISEASES. 

ommends that after exposing the organ through a vertical 
incision, the fatty capsule be opened, the kidney seized 
and the fatty capsule removed by dissection. The fibrous 
capsule is then scarified to a degree just short of haemor- 
rhage with two cambric needles held in hamostatic 
forceps. A strip of iodoform gauze twelve inches in 
length and two in width is carried underneath the lower 
pole of the kidney, some advise that the upper pole be 
treated in the same manner. A gauze pad is placed over 
the exposed portion of the kidney and the gauze sling tied 
over it. The region beneath and around the organ is 
packed with gauze. The external wound is not sutured. 
A pad should be placed over the hypochondriac region to 
reinforce the gauze packing. The gauze beneath the 
kidney should be moved on the sixth and the sling on 
the eleventh day after the operation. To insure success 
the patient should remain in bed for the succeeding six 
or seven weeks, no matter what method is used, in order 
to allow the exudate to become thoroughly organized and 
capable of holding the kidney firmly in its place. The 
neurasthenic state so common in movable kidney is rarely 
cured by a nephropexy and the operation is often unsuc- 
cessful. 

Pyelolithotomy. — It was formerly advised, when the 
exploratory incision revealed a stone in the pelvis of the 
kidney, that an incision should be made into the side of 
the renal pelvis and the stone extracted ; but experience 
has demonstrated that while the pyelolithotomy was suc- 
cessful, a renal fistula usually resulted. These are very 
troublesome and are rarely, if ever, successfully obliterated. 
Kelly, in the Medical News, Nov. 30, 1895, reports a 
case of pyelolithotomy in which the pelvis of the kidney 
was opened on its posterior wall and a calculus removed. 
The pelvis was approximated with catgut sutures, the lum- 
bar opening closed, and recovery was rapid and perfect. 



RENAL SURGERY. 259 

Nephrolithotomy. — When a calculus is discovered in 
the substance of the kidney or its pelvis, either by touch, 
the X-rays, the introduction of needles into the substance of 
the kidney or a trocar when fluids are apparently present, a 
nephrolithotomy is indicated. An assistant should press 
upon the front of the abdomen and push the kidney back 
to its normal position, so as to make it more readily recog- 
nizable. In nephrolithotomy the incision should be made 
longitudinally along the free convex border of the kidney, 
and of sufficient length and depth to allow the finger to be 
introduced into the calices of the pelvis. If a calculus is 
found it may be removed by the finger or with a pair of 
forceps. After it is extracted the parts must be well 
flushed with a normal saline solution, a drainage tube in- 
troduced nearly to the opening of the pelvis of the kid- 
ney, the incision of the kidney drawn together with proper 
sutures, or the wound may be packed, dressed antisep- 
tically and allowed to close by granulation. In operations 
upon the kidney, hemorrhage is usually slight and is easily 
controlled by packing with Iodoform gauze. 

Nephrotomy. — In abscess of the kidney or in pyelo- 
nephritis, the kidney is opened as advised in nephrolitho- 
tomy. The cut edges of the kidney may be sutured to 
the margin of the incision in the lumbar region, to facili- 
tate drainage and prevent the pus from burrowing. In 
large abscesses of the kidney it is advisable first to 
make a nephrotomy for drainage, and later, when indi- 
cated, a nephrectomy. A nephrotomy is often considered 
advisable to relieve tension when the kidney is over- 
charged with blood, as in acute productive nephritis, etc. 

Nephrectomy. — This operation may be required in cer- 
tain injuries of the kidney, or when degeneration or new 
growths render the organ useless or a menace to the system 
in general. Occasionally a persistent renal haemophilia, the 
complication of a movable kidney, a calculus kidney, or a 



260 UROPOIETIC DISEASES. 

ureteroabdominal fistula may necessitate removal of the 
organ. Before a nephrectomy is advised or made, the con- 
dition of the other kidney should always be interrogated. 
The technique in nephrectomy is as follows : The lumbar 
incision is made, the kidney found and freed from its at- 
tachments by the index finger, care being taken not to 
enter the peritoneal cavity or to rupture any vessel, 
whether normally or abnormally situated. The kidney 
when freed from all its attachments, with the exception of 
the ureter and its vessels, is gradually and carefully lifted 
from its bed and an aneurism needle with a stout silk liga- 
ture passed under the ureteral pedicle. The needle is cut 
out, the two ligatures separated about three-fourths of an 
inch and tied, the pedicle cut between them and the kid- 
ney removed. The ligatured ureteral end is cut close and 
allowed to drop back into the wound ; a rubber drainage 
tube is introduced and the wound closed. If the hemor- 
rhage is severe, the vessels are secured by artery forceps, 
which are allowed to remain for a time they also facilitate 
drainage. If the peritoneum is accidentally opened, it 
must be carefully closed with catgut sutures. 

The kidney may be removed by the abdominal route 
(abdominal nephrectomy) but it is not as acceptable or ad- 
visable as the lumbar ; the true floating kidney may, how- 
ever, require it. The latest method for performing 
it is suggested and its usefulness demonstrated by Dr. 
Robert Abbe. The advantages are as follows : It al- 
lows operation in the most advantageous position for the 
patient and operator. It gives about the best access to 
the kidney and ureter. It is free from hemorrhage, as 
no muscles are cut. It allows of immediate suturing of 
the separated muscles, with strongest possible condition 
of the abdominal wall, precluding subsequent hernia. At 
a meeting of the N. Y. Surgical Society, Feb. 24, 1897, 
he presented a kidney removed by his method ; the wound 



RENAL SURGERY. 261 

healed by primary union and the patient was out of bed 
on the tenth day. The operation is as follows : An in- 
cision is made from a point one inch inside the anterior 
superior iliac spine and carried upward and backward 
four and a half inches, in a line parallel with the fibres 
of the external oblique muscle. The muscular fibres are 
parted with the index fingers, and an opening, which ad- 
mits of all necessary manipulation, is readily made without 
dividing any muscular fibres. The peritoneum having 
been reached, the index finger is pressed backward to the 
perirenal fat, and readily sweeps the peritoneal sac off the 
front of the kidney. With good retractors the pedicle can 
be inspected and the ureter separated. In case the opera- 
tion is for a hydro- or pyonephrosis, aspiration will empty 
the fluid and reduce the bulk of the tumor before removal. 
Through the anterior incision the finger can follow the 
ureter to the brim of the pelvis, where it can be tied 
off with a catgut ligature. After removal of the kidney, 
the abdominal wall falls together in the lines of muscu- 
lar separation, and three catgut stitches are applied to 
each. A small rubber drainage tube may be inserted 
for one day if there has been extensive stripping of the 
tissues, but this is usually unnecessary. 



CHAPTER XXIV. 
ALBUMINURIA OF PREGNANCY. 

Etiology. — In the latter months of pregnancy, albu- 
minuria, convulsions, etc., sometimes occur, with serious 
after-effects, and not infrequently with fatal termination ; 
this is true in primiparse, and especially in twin-preg- 
nancy. The most severe manifestations show them- 
selves during labor or immediately afterward. In multi- 
parse, the symptoms are less severe, but there is a greater 
tendency for the condition to terminate in a productive 
form of nephritis. Many explanations have been offered 
as to the cause of this condition ; all are apparently defect- 
ive and none have been universally accepted. 

Pathological Anatomy. — There is no special and char- 
acteristic kidney lesion. Eclampsia has developed when 
the kidneys were normal, when in a state of acute degen- 
eration, acute parenchymatous nephritis of the exudative 
or productive varieties, in chronic parenchymatous or in- 
terstitial nephritis, and in cystic degeneration. 

Clinical History. — This disease may practically be di- 
vided into three varieties ; first, a small class where often 
albumen has not previously been present in the urine, and 
where from some unknown cause the urine becomes 
suddenly highly albuminous, greatly reduced in quantity, 
even verging on suppression, with pronounced deficiency 
in the quantity of urea, together with marked cerebral 
symptoms, convulsions, stupor, coma, vomiting, deficient 
vision, headache, arterial tension, rise in temperature, 
etc., all or a portion of these symptoms being pres- 



ALBUMINURIA OF PREGNANCY. 263 

ent in a given case, which, if not quickly relieved, re- 
sult in death. . If the treatment is successful, the cere- 
bral symptoms gradually subside and the urine returns 
to a normal condition. This form of puerperal albu- 
minuria is most frequently met with in primiparae. 
Second, a class often appearing in multiparse, where in 
the later stages of gestation the urine becomes scanty and 
albuminous, accompanied by considerable anasarca. They 
usually go through labor safely, but the kidney lesion 
passes into a sub-acute productive nephritis, which be- 
comes chronic. Third, a class characterized by a daily 
increased secretion of an albuminous urine, deficient in its 
percentage of urea. General symptoms are frequently 
absent, and confinement may be passed without accident ; 
this variety frequently occurs in multiparse and usually 
subsides after confinement, or it may terminate in chronic 
nephritis. When the urine contains serum albumen, the 
case generally ends fatally or terminates in chronic ne- 
phritis. When the albumen is largely paraglobulin, 
eclampsia may be expected ; in the more chronic cases, 
and when the condition is due to intra-abdominal press- 
ure, the symptoms quickly subside, as soon as the pressure 
is removed by delivery of the fcetus. 

In the last two forms, the prominent symptoms may ex- 
tend over a period of weeks or months. In the first the 
advent is sudden and often leads to the death of the fcetus 
in utero, as well as of the patient. 

Treatment. — Professors Smiley and Fryermuth in their 
respective papers in the Medical Century, April, 1900, 
give the following excellent symptomatic indications : 

Aconite : Premonitory symptoms of puerperal eclampsia 
may be ameliorated if not entirely removed by the use of 
Aconitum — especially in plethoric young women who 
have not borne children — when in the beginning of labor 
the skin is hot and dry with feverish thirst and great rest- 



264 UROPOIETIC DISEASES. 

lessness, cerebral congestion with great fear and anxiety. 
Three doses a half hour apart will leave nothing to be de- 
sired in the way of medication. 

Argentura nitricum : The patient is in constant fear and 
expectation of approaching spasm. In tie interval be- 
tween the spasms she is never for a moment quiet. The 
paroxysms are exceedingly violent, and are preceded by a 
sensation of expansion of the whole body, but more 
especially of the head and face. She becomes exceedingly 
restless just before a spasm begins. 

Apis mellifica : When oedema appears suddenly, espe- 
cially under the eyes. Anasarca when the flesh is sensitive 
to touch or pressure of the bed or chair. Alternate 
moisture and dryness of the skin. Urine is suppressed or 
scanty, high-colored, offensive and contains albumen, blood 
corpuscles, epithelium and uriniferous tube casts. 

Arnica montana: When indicated in the premonitory 
stage the pulse is full and strong, and every pain sends the 
blood rushing violently to the head and face, while the 
body remains cool or of a normal temperature. There 
may be symptoms of paralysis of the left side, or complete 
loss of consciousness and involuntary discharge of stool 
and urine. 

Belladonna : This remedy is indicated when the spasms 
are fully developed ; during labor every pain brings on a 
spasm, when the face and neck become livid, the parotid 
and temporal arteries pulsate violently ; the eyes are red 
and congested and stare rigidly. In the interval between 
the spasms there are jerking and twitching of the muscles, 
more or less tossing about, with convulsive movements of 
the limbs and muscles of the face, with semi-consciousness 
and loss of speech. There may be paralysis of the right 
side of the tongue and difficult deglutition with foaming 
of bloody saliva at the mouth. Belladonna would not be 
c . ntra-indicated if instead of livid countenance the face is 



ALBUMINURIA OF PREGNANCY. 265 

pale and cold with shivering and sound sleep after a par- 
oxysm, with involuntary escape of faeces and urine. 

China officinalis: If the exciting cause of the convul- 
sions be the loss of a large quantity of blood China would 
be indicated, provided the other symptoms agree. 

Coffea cruda : When spasms are threatened by the pres- 
ence of extreme excitability of the nervous system, and 
the extremities are cold and the patient grinds her teeth 
from nervousness, Coffea is the remedy. 

Cuprum arsenicosum : Is useful when pregnancy occurs 
in a woman with chronic nephritis, and whose heart gives 
evidence of becoming involved. The urine has the odor 
of garlic. 

Cuprum metallicum : When the spasms begin as cramps 
in the fingers and toes, extending through the limbs to the 
whole body, complicated with violent vomiting ; opis- 
thotonos with every paroxysm, and spreading out of the 
limbs and opening of the mouth, Cuprum metallicum will 
meet the conditions most admirably. 

Gelsemium : Is often indicated in malarial regions, and 
in the western country where "mountain fever" is so 
prevalent. The symptoms will simulate incipient typhoid 
fever. While the headache of this remedy is usually 
occipital, it may affect the sinciput. Gelsemium is often 
required to meet the premonitory symptoms, as when the 
head feels very large, patient is irritable, sensitive, a ner- 
vous dread of the near approach of labor. There are chilly 
waves running up and down the spine from occiput to 
sacrum, and pains running from before backward in the 
abdomen and also from pelvis to diaphragm. Give the 200X 
in water every two hours till relieved. It will require two 
or at most four doses. 

Glonoin : Has abundant, highly albuminous urine, 
which the patient must rise at midnight to pass ; urine is 
high-colored, and burns. The free discharge of urine indi- 



266 L'ROPOIETIC DISEASES. 

cates renal fullness, and is associated with symptoms of 
congestion to the head, with the peculiar headaches of the 
remedy. 

Helonias : This remedy gives excellent results in albumi- 
nuria during pregnancy with drowsiness and marked 
weakness. "Helonias is a diuretic; and, when in full 
action, the kidneys have a burning feeling, and they ache ; 
evidence of venous congestion and retarded blood flow." 
The patient has a tendency to colic which passes away 
during employment. 

Hyoscyamus : Attention is called to Hyoscyamus by the 
bluish color of the face with twitching and jactitation of 
every muscle of the body, together with those of the face, 
eyes, lids, and extremities, with almost constant delirium. 

Mercurius corrosivus : This remedy was highly lauded 
by the late Prof. Ludlam as a remedy of great value in 
albuminuria occurring during pregnancy. " I have pre- 
scribed it very frequently to fulfill this precise indication 
and it has seldom disappointed me," is his testimony. The 
urine is scanty; the patient is troubled at night with fre- 
quent and scanty discharge ; yellowish tint of the skin. 
Probably the good results obtained from the remedy are 
due as much to its action on the liver as on the kidneys. 

Opium : The indication for Opium is called to mind by 
the constant stertorous respiration both on- inhalation and 
exhalation, with heavy, stupid sleep, red face, half closed 
eyes, incoherent wandering and convulsive rigidity of the 
body, redness, swelling and heat of the face, hot perspira- 
tion, invisible pupils, black, offensive, involuntary stools, 
bladder full of urine, but no force to expel it. The proxi- 
mate cause of the spasms may be suppression of the labor 
pains. 

Stramonium: This medicine is particularly indicated 
where the patient shows such signs of fear as to cause her 
to look frightened and to shrink back from the first objects 



ALBUMINURIA OF PREGNANCY. 267 

she sees after opening her eyes. When betraying such 
symptoms she will soon have spasms, unless Stramonium be 
given at once and the spasm be thereby prevented. The 
same frightened appearance occurs, also, after the con- 
vulsions commence. The eyes are wide open, pupils 
widely dilated, which gives them a decidedly brilliant ap- 
pearance. She is disposed to talk, laugh, pray and entreat 
continually, but not always coherently. She may merely 
stammer or even lose speech altogether from loss of con- 
sciousness. The fits are precipitated by the sight of brill- 
iant objects and sometimes by contact. 

Terebinthina : Should always be thought of when the 
urine is highly charged with blood, indicating haemorrhage 
from the kidneys. 

Uranium nitricum : The patient must rise often during 
the night to urinate, urine is very acid. She is de- 
spondent, ill-tempered and disagreeable. The mammary 
glands are unusually developed and in the latter months of 
gestation the secretion is poured out so abundantly as to 
keep the clothing wet. 

Veratrum viride : When chosen in a case of puerperal 
eclampsia there must be great activity of the arterial sys- 
tem, without the great fear, fright and anxiety which 
belong to Aconitum. The face is blue and livid, with 
profound coma or wild delirium, caused by the intense 
congestion of blood to the head. There have been during 
the whole period of pregnancy severe vomiting and con- 
stant nausea, with severe burning pain in the stomach. 
Premonitory symptoms of convulsions, for which this 
remedy is specific, are slight chilliness, with some nausea and 
twitching of the muscles of the face, followed by a rapid 
convulsed movement of muscles of body and limbs ; dilated 
pupils, difficult breathing, followed by stupor from which 
it is difficult to arouse patient. Afterward pain and press- 
ure in the head, with profound nausea and faintness. Con- 



268 UROPOIETIC DISEASES. 

vulsions with mania, or the mania may continue after the 
convulsions have ceased." 

General treatment should be instituted as soon as the 
condition is discovered, especially if any symptoms of 
toxaemia or cerebral symptoms are present, i. e., headache, 
vertigo, nausea, vomiting, loss of sight, hearing, dyspnoea, 
etc. 

All modern authorities agree that in pregnancy, with 
albuminuria and symptoms of toxaemia, emptying of the 
uterus is of vital importance. This can be accomplished 
in three ways : If the case is not urgent, after the parts 
are made perfectly aseptic the cervical canal can be dilated 
with a steel dilator, then packed with sterilized gauze, and 
the vagina tamponed ; the tampon should be removed in 
from twenty-four to thirty-six hours. Previous to the 
sixth month, this may be repeated daily until the cervix is 
sufficiently softened to allow of curetting. Hemorrhage is 
sometimes severe, and, when profuse, a uterine tampon 
may be required. After the seventh month, and the case 
is not too urgent, a tampon should be used for twenty-four 
hours, followed with manual dilatation and delivery, with 
the usual after treatment. Others require manual dilata- 
tion within an hour to save the life of the mother, and 
still others, from deformity, may require Caesarean sec- 
tion. 

Kdgar in the Medical Record, Dec. 26th, 1896, sum- 
marizes the accepted treatment of to-day as follows : 

" Prevention has three indications. To reduce the 
amount of nitrogenous food to a minimum ; limit the pro- 
duction and absorption of toxic materials in the intestines 
and tissues of the body, and assist in their elimination by 
improving the action of the bowels, the kidneys, the liver, 
the skin, and the lungs ; if necessary, remove the source 
of foetal metabolism and of peripheral irritation in the 
uterus by the emptying of that organ. 



ALBUMINURIA OF PREGNANCY. 269 

"The reduction of the amount of nitrogenous food to a 
minimum can best be fulfilled in an exclusive milk diet, 
to which, as the symptoms subside, can be added fish and 
white meats. He has found it not only safer, but less try- 
ing to the patient, to commence with an absolute milk 
diet, than to compromise and afterward be compelled to 
cut off all but the milk. 

" Elimination must be secured by an abundant supply 
of pure air and water, assisted by moderate exercise or 
light calisthenics or massage in certain instances. For the 
bowels he advocates daily doses of Colocynth and Aloes at 
bedtime, followed by a saline in the morning. For the 
liver an occasional dose of Calomel and Soda at bedtime, 
followed in the morning by one of the stronger sulphur 
waters, as Rubinat, Villacabras, or Birmenstorf. Increased 
diuresis is secured by maximum doses of Glonoin. The 
action of the skin is encouraged by encasing the body in 
wool or flannel underclothing, by massage, by the warm 
bath, hot bath, hot pack, or hot air bath, according to the 
urgency of the case. 

" In instances of eliminative insufficiency he gives at 
bedtime twice weekly, or more frequently if necessary, a 
tablet composed of Calomel, Digitalis, and Squills, each 
one grain, and Muriate of Pilocarpine, one-twentieth of a 
grain, followed in the morning by a full dose of Villaca- 
bras water. 

" Finally, when exercise cannot be taken and an abund- 
ant supply of fresh air is wanting, oxygen inhalations 
will prove of service. 

" Every case must be treated on its merits. In one a 
restricted diet and mild stimulation of the renal and intes- 
tinal functions is sufficient, and the patient may be allowed 
to be about and even exercise in the open air, the skin 
being protected from sudden changes by being incased in 
wool or flannel. More pronounced cases of eliminative 



270 UROPOIETIC DISEASES. 

insufficiency must be kept absolutely quiet in bed, upon 
an exclusive milk diet, with the stimulation of all the 
eliminative organs. 

" The hygienic and medicinal treatment is only of 
secondary importance to the milk diet, which is the foun- 
dation of the preventive treatment of puerperal eclampsia. 
When, in spite of an exclusive milk diet and the vigorous 
stimulation of the five excretory outlets, the symptoms 
and signs of the pre-eclamptic condition continue or at 
any time become urgent, the indication is to induce arti- 
ficially abortion or premature labor. 

"Curative treatment also has three indications : To con- 
trol the convulsions; eliminate the poison or poisons 
which we presume cause the convulsions ; empty the 
uterus under deep anaesthesia by some method that is 
rapid and that will cause as little injury to the patient as 
possible. 

" The four medicinal means most certain and safe as 
anti-eclamptics are Chloroform, Morphine (hypodermati- 
cally), Veratrum viride, and Chloral hydrate, the latter 
alone or combined with Sodium bromide. His preference 
is for Chloroform, Veratrum viride, and Chloral, in the 
order named. Morphine he has abandoned almost en- 
tirely, as he believes it prolongs the post-eclamptic stupor 
and increases the tendency to death during coma by inter- 
fering with the eliminative processes. 

" Second only to Chloroform in value is Veratrum 
viride. Provided the pulse be strong as well as rapid, it is 
the most certain means for temporarily and even perma- 
nently controlling the convulsions. When the pulse is 
weak he relies upon Morphine hypodermatically, Chloro- 
form by inhalation, and Chloral by rectum, with stimula- 
tion if necessary. 

" Veratrum viride reduces the pulse rate, convulsions 
are practically unknown with a pulse rate of sixty 



ALBUMINURIA OF PREGNANCY. 271 

or under ; it reduces the temperature ; it relaxes and 
renders more yielding the rigidity of the cervical rings ; 
it causes prompt diaphoresis and diuresis, so that it 
aids not only in the fulfilment of our first indication the 
control of the convulsions, but in the second the elimina- 
tion of an unknown poison as well. Norwood's tincture 
should always be used ; five drops hypodermatically, or ten 
to thirty drops by mouth, as the pulse, etc., indicates. 

"Catharsis is secured as early and as promptly as possi- 
ble by the administration of Croton oil, compound Jalap 
powder, or Calomel, followed by salines and high enemata 
of Magnesium sulphate. In the coma or post-eclamptic 
stupor of the condition, the repeated administration of 
concentrated solutions of Magnesium sulphate or Villaca- 
bras water, by means of a long rectal tube high up in the 
descending colon are reried upon. The hypodermatic admin- 
istration of Magnesium sulphate is too slow and uncertain. 
Diuresis is obtained by dry or wet cups over the kidneys, 
followed by hot fomentations. Glonoin, as a diuretic and 
anti-eclamptic, cannot be over-estimated. Diaphoresis is 
encouraged by means of the hot-air bath or the hot pack. 
Pilocarpine, as a diaphoretic, in the presence of an ec- 
lamptic attack, is utterly rejected, because of the danger of 
oedema of the lungs and glottis which it may produce. 
The drawing off of large quantities of toxic liquids in the 
form of blood or serum, by means of venesection, catharsis, 
diaphoresis, diuresis, followed by the replacement of the 
same by intravenous, stomachic, rectal or hypodermatic 
means, causing a washing or disintoxication of the blood 
and tissues as it were, has thus far proved of doubtful 
value. In instances of collapse, however, with the small 
compressible pulse, the introduction into the blood of a 
normal saline solution is of the same value here as in col- 
lapse under other circumstances. As a general stimulant, 
to assist in the elimination from the lungs and to prolong 



272 UROPOIETIC DISEASES. 

life in the post-eclamptic stupor or coma, he has found the 
free administration of Oxygen of the greatest value. 
Further, Alcohol will often be needed as a stimulant dur- 
ing and after an eclamptic attack, and Strychnine in the 
post-partum state and in the face of threatened collapse, 
although for physiological reasons it would seem to be 
contra-indicated. ' ' 



CHAPTER XXV. 

UREMIA. 

Foster defines uraemia as "a poisoned state of the blood, 
due to defective elimination of the elements of the urine 
in consequence of impairment of the functional capability 
of the kidneys, or, by their re-absorption in the cases of 
retention of urine, characterized by stupor and, especially 
in lying-in women, by convulsions." Bouchard says 
uraemia is an intoxication of the system " by all the 
poisons normally introduced into, or found in the organ- 
ism, which ought to have been eliminated by the renal 
path, and are prevented from being so owing to the im- 
permeability of the kidneys." 

Etiology. — When the condition that is now recognized 
as c uraemia was classified, it was supposed to be due, ac- 
cording to " the Wilson theory," to an excess or retention 
of urea in the blood, but as experiments multiplied it was 
found that uraemic symptoms were sometimes present 
when the blood contained no urea, although if urea was 
introduced either directly into the blood current or indi- 
rectly through the stomach, or the ureters tied, and no 
fluids injected, many symptoms of uraemia soon appeared. 
It was further observed that often cases of complete anuria 
were not followed by uraemia. This and other facts led to 
the rejection of this theory, and the advancement of the 
idea that uraemia only occurred when the urea in the 
blood was in some manner decomposed into Carbonate of 
ammonia, by a peculiar organized ferment, as advocated 
by Frerich ; but in the light of modern investigation, this 
18 



274 UROPOIETIC DISEASES. 

theory, like Schottin's, which claimed that uraemia was 
produced by the presence of the excretory products, Creatin, 
Creatinin, Leucin and Tyrosin, etc., proved inadequate. 
Traube was of the opinion that it was the result of 
cardiac hypertrophy, hydraemic conditions of the blood, 
and cerebral oedema ; but this, too, was found to be want- 
ing, as well as Bence-Jones' oxalic acid, Thudicum's 
urochrome and Feltz and Ritter's potass intoxication. 
The Jour, de Med. et de Chir. Pratique, July 10, 1895, 
says that uraemia is caused by the following conditions : 
" First, a dominating toxic element, caused by the failure 
of the diseased kidney to perform satisfactory elimina- 
tion of the debris of the organism. Second, a mech- 
anical factor, cerebral oedema, the localization of which 
in the motor zones may cause convulsions, either general 
or limited to one side, to one member or merely to 
several facial muscles. In some cases the uraemia presents 
an apoplectic form, in others it is hemiplegic, both de- 
pendent, however, upon cerebral oedema." The writer 
further remarks that many cases of hemiplegia, usually 
supposed to be due to cerebral haemorrhage or soften- 
ing, in which the autopsy shows no evidences of dis- 
ease or extravasation of blood into the cerebral tissue, 
are due to this cerebral oedema, which disappears on the 
death of the subject. 

Bouchard's investigations are of importance and deserve 
special consideration. He says the system for various rea- 
sons is constantly threatened with toxaemia from the accu- 
mulation of poisonous materials in the blood which escape 
through the action of the general emunctory apparatus ; 
the lungs, kidneys, etc., eliminating those formed in the 
tissues, the liver serving as a barrier to poisons entering 
the blood from the alimentary canal. The emunctory 
function of the kidney is of the utmost importance to 
health ; any decrease in the toxicity of the urine voided 



UREMIA. 275 

is proportionately evidenced by symptomatic evidence of 
disease. Normal urine of sufficient quantity when ex- 
perimentally injected into the veins of an animal produces 
inyosis, which gradually increases until the pupil becomes 
pin-pointed, accompanied with diminution of palpebral 
and corneal reflexes, the pupil remaining contracted until 
after death. The respiratory acts are increased in frequency 
and diminished in range, muscular movements grow irreg- 
ular and laborous accompanied with somnolence, polyuria 
and fall of temperature, death resulting without convul- 
sions, though moderate muscular tremor may be present, 
with persistence of the cardiac beats and contractility of 
the striated and the non-striated muscle fibres. 

" If only the smallest poisonous quantity of normal 
urine is injected into the veins of the animal sufficient to 
produce coma but not death, the animal will remain pass- 
ive with respiratory movements of feeble range, chilled 
with pupillary contractions and with polyuria such that 
every two minutes an emission of urine takes place. The 
superficial vessels dilate and the arteries beat with 
such amplitude that their pulsations will be easily felt up 
to the tip of the ear. Then torpor diminishes, the fall of 
temperature is arrested, heat production goes on again and 
the pupil dilates. At the end of half an hour return to 
health is definite without secondary phenomena." If patho- 
logical urine of certain kinds was injected, albuminuria 
and sometimes hsematuria resulted. 

From his experiments it would appear that a healthy 
man excretes through the kidneys poisons sufficient, if re- 
tained in the system, to produce death in two days and 
four hours. The toxicity of normal urine varies, however, 
with the degree of cerebral or muscular activity, the 
amount of sleep, the character of diet and the general con- 
dition of the system, it being greatest, all things being 
equal, in the early part of the day and during cerebral and 



276 UROPOIETIC DISEASES. 

muscular activity, and lowest during rest and sleep. These 
poisons of the urine act upon the nervous system and par- 
alyze movement, but do not destroy muscular contractility. 

Bouchard has separated seven toxic principles from the 
normal urine, which, by physiological experimentation, 
he has found to produce symptoms similar to those of 
uremia, the character of the ursemic manifestations de- 
pending upon the nature of the pathological lesion, and 
consequent retention in the system of varying amounts of 
the various toxic principles and their necessary auto- 
intoxication. 

When urea is intravenously injected into animals, 
diuresis, diminished respiration, tremors and convulsions 
are produced, but the temperature is not lowered, the 
animal dying comatose due to retarded osmosis. From 
comparison by weight of the poisoned animal with man, 
it would take nineteen times the quantity of urea elimi- 
nated in a day to cause his death ; or, in other words, com- 
plete suppression of the urine for nineteen days. Uric acid 
does not seem to possess any toxic property ; only fifty to 
sixty centigrammes are eliminated daily by the average 
man; the gouty subject often has hundreds of grammes 
of the urates in his system without evidencing ursemic 
intoxication. 

If the odoriferous substances of the urine are eliminated 
by evaporation its toxicity is increased; if the coloring 
matters are removed by decolorization with carbon, ex- 
periment shows that it loses one-third of its toxicity. This 
latter loss of toxicity is not due entirely to the removal of 
the coloring matters, but to the potash and alkaloids, 
as about one-sixteenth of the former, and nearly the 
whole of the latter are removed at the same time. This 
proves that there are other toxic principles besides potash 
present in the urine. Again, if the urine discharged has 
lost but one-third of its toxicity and the power to contract 



UREMIA. 277 

the pupil, the whole of the toxicity does not reside in the 
alkaloids. 

By the dichrotomic method, the alcoholic solution of the 
residue differs from the aqueous in its action. The aqueous 
extract produces tonic convulsions, accompanied by 
straightening of the head, opisthotomos|; vibratory tremor 
and death. The alcoholic produces marked and rapid 
contractions of the pupils, followed by oscillation, the 
animal passes into a sleepy state, lies on its side, the pupils 
dilate gradually, and, while comatose, urinates and sali- 
vates profusely. There is, however, no fall in the bodily 
temperature. 

The seven toxic principles in the urine described by 
Bouchard are as follows : (i) Urea, which is admitted to 
have the power of removing through the kidneys not only 
the water in which it is dissolved, but other toxic mate- 
rials; while it is somewhat toxic its property of induc- 
ing rapid elimination protects the system. (2) A narcotic 
of organic nature not fixed by carbon, soluble in alcohol 
and found in the alcoholic extract with urea. (3) A sialo- 
genous substance which produces salivation found in 
minute granules. It acts slowly, and does not demonstrate 
its presence by urinary poisoning except when separated 
into its component parts. (4 and 5) Two substances hav- 
ing the power to produce convulsions. One is a fixed 
alkaloid of unknown name, staple, organic, destroyed by 
carbonization, yet retained by carbon and insoluble in 
alcohol. (6) A substance, probably a coloring matter, 
which causes contraction of the pupil. It is fixed, organic, 
non-metallic and attaches itself to carbon. (7) Potash, an 
inorganic substance, the toxic and convulsive powers of 
which are well-known, though its activity is slow as com- 
pared with the organic substances already described, which 
kill before the potash could accumulate in sufficient 
amount to destroy life. 



278 UROPOIETIC DISEASES. 

Diseased conditions of the kidneys inhibit the diuretic 
action of urea and the quantity of the urine is in conse- 
quence diminished. If the relative amount of urea is not 
produced in the system the functional activity of the 
healthy kidney will be impaired. 

Uraemia is not an early manifestation of kidney disease, 
but only appears when the permeability of the kidneys are 
so diminished that they can no longer eliminate in a 
given length of time the quantity of toxic materials 
formed in the organism during that period. When this 
happens, chronic and paroxysmal nervous conditions ap- 
pear, characterized by pain in the head, dyspnoea of the 
Cheyne-Stokes type, vomiting, diarrhoea, convulsions, 
coma, change in temperature, etc. With these ursemic 
manifestations a change in the toxicity of the urine be- 
comes apparent ; in fact, the toxicity of the urine voided 
by a ursemic patient often does not exceed that of distilled 
water, while the blood and muscles will be found to contain 
an excess of urea, though Bouchard's experiments prove that 
it requires a quantity of urea equal to that produced in the 
system of a man in nineteen days to cause his death ; yet 
in complete double calculous obstruction of the ureters 
death has occurred during the second or at the beginning 
of the third day, which goes to prove that while urea is 
toxic, death must have been due to other associated 
poisons in the urine, which are the coloring matters, as 
the urine loses one-half its toxicity by decolorization. 
Bouchard recognizes that one-seventh to one-eighth of 
the total toxicity of the urine is due to urea, a trace to the 
ammonia, and two-fifths to the coloring matters, the 
latter being fixed by carbon and having their own pecu- 
liar actions. The combined organic materials represent 
two-thirds of the toxicity of the urine, the remaining 
third being of mineral nature and largely potash, the 
soda being practically inert. 



UREMIA. 279 

Clinical History. — The symptomatic manifestations of 
uraetnic intoxication can best be described as special symp- 
toms which vary in degree in individual cases. 

Headache is one of the early symptoms. It may be 
mild, severe, transitory or continuous; sometimes it is 
so intense and protracted as to produce sleeplessness. In 
the acute forms of uraemia it is accompanied by arterial 
tension and diminished secretion of urine. In the chronic 
form the urine is often diminished, the specific gravity low- 
ered and arterial tension is not constant. 

Sudden blindness, uraetnic amaurosis not due to retinitis, 
is often developed during the puerperal state, and in 
chronic nephritis. The cause of this symptom is un- 
known. It may last for hours or days, and may precede or 
follow convulsions; it is sometimes accompanied by 
ursemic deafness. 

Contractions of single muscles or groups of muscles 
sometimes occur in the more severe cases of uraemia, and 
are usually the forerunner of the approaching convulsion. 

The onset of convulsions is usually sudden ; there may 
be one or many, and they may follow each other at inter- 
vals of minutes or hours ; they may be epileptiform in char- 
acter or assume the Jacksonian type. Consciousness may re- 
turn between the attacks or the patient may remain in a 
state of coma ; uraemic convulsions may develop in mild as 
well as in the more severe cases of acute nephritis, and may 
be expected when the urine is diminished or suppressed with 
marked arterial tension ; recovery is the rule. When oc- 
curring in chronic interstitial nephritis and in the puer- 
peral state, developing before, during or after labor, ac- 
companied with the same arterial tension and urinary 
symptoms as in acute nephritis, the termination is more 
likely to be fatal. 

Delirium and coma may appear in uraemic conditions. 
These, with convulsions, may develop slowly or rapidly 



280 UROPOIETIC DISEASES. 

during the course of Bright's disease, especially in the 
acute and in the exacerbations of chronic nephritis. The 
coma may be continuous, progressive or transitory. The 
face pale or flushed ; the pupils dilated, contracted or nor- 
mal. The breathing is often hissing in character, and is 
observed in the more severe forms of ursemic coma. 

Dr. Baillet, of Paris, in a paper on the different forms of 
ursemic paralysis, translated by Dr. Pritchard, of Monroe- 
ville, Ohio, in N. Y. Med. Times, says: " Whatever be the 
nature of the nephritis or of its prodromal signs, the 
paralysis does not set in, in two-thirds of the cases, all of a 
sudden ; it is accompanied by convulsions or begins with 
coma. These are observed particularly in sub-acute cases, 
in the course of which they represent in certain cases a 
prodromal phenomenon. More frequently they precede the 
motor disorders. Their similarity to the convulsions of 
essential epilepsy is perfect, yet they may appear under the 
most varied forms. Loss of consciousness, obliviousness 
of the attack, a succession of tonic and clonic phases, 
spasms throughout the whole body and of the face ; still, 
in some cases there is not the initial cry, the biting of the 
tongue, nor the flexing of the thumb into the palm ; some- 
times the tonic stage is absent. The convulsions may be 
limited to one side of the body, to one limb, to the face, 
and presenting the characteristics of Jacksonian epilepsy 
they are accompanied by loss of consciousness, contrary to 
what is observed in epilepsy local of other origin. The 
partial convulsions are situated on the same side of the 
body as the motor disturbances, and they are not constant 
as to the moment of their appearance nor in their mani- 
festations. They may appear at intervals of several days 
(Giammattei) under different aspects ; unilateral in the first 
seizure, then generalized in the second (Finlagson). In 
duration they vary from a few minutes (Chantemesse and 
Tenneson) to several hours (Raymond), from nine hours 



UREMIA. 281 

(Finlagson) to two days (Dunin). When the attacks recur 
frequently there is an actual status epilepticus. These 
partial convulsions may be noted without paralysis ; yet 
this is exceptional. 

" Not less frequently than the convulsions to which they 
often are joined is coma, which may constitute an initial 
phenomenon of the ursemic paralysis. Suddenly the patient 
falls into a state of complete muscular helplessness, with 
insensibility to all external stimuli. This comatose state 
may often be present in any degree, but very often it is 
represented by a state of stupor ; consciousness is not 
wholly abolished ; he is able to speak a few words, to 
answer a question shouted at him, or one may elicit a gest- 
ure in response to an order repeated with emphasis. It is 
often that a conjugate deviation of the eyes and head, or a 
deviation of the face, will put the physician upon the right 
track, that a paralysis is present, which is confirmed by 
lifting the limbs from the bed. This period of coma is 
frequently transitory. It lasts from a few minutes (Ray- 
mond) or more ; it may persist for three days (Chaute- 
messe and Tenneson). Again; it may be repeated several 
times within the same day (Boinet). In one-third of 
the cases the paralysis occupies at once the foreground, 
without convulsive or comatose phenomena. Spasmodic 
disorders rarely complicate its development ; as to the 
coma, it constitutes the usual termination of ursemic 
paralysis, which ending is death. 

" Uraemia generally (63 per cent.) assumes the right or 
left-sided hemiplegic paralysis indifferently. This hemi- 
plegia is total or partial. In about one-half the cases, par- 
ticularly when right-sided, it takes on the brachio-crural 
form. Very often (15-20 per cent.) it may be brachial mon- 
oplegic, which is more often isolated than when associated 
with facial paralysis. This monoplegia is preferably right- 
sided, and then it is many times associated with aphasia. 



282 UROPOIETIC DISEASES. 

Facial paralysis, often accompanying hemiplegia and 
sometimes monoplegia, is rarely present alone. The other 
types of paralysis are exceptional ; as, for example, the 
two cases of paralysis of the vocal cords reported by Ivins, 
the hemiplegia alterna with Weber's syndrom (Tackel), the 
ocular paralysis, strabismus and ptosis, the bilateral 
paralyses, brachial diplegia or quadriplegia (Giammattei). 

u The beginning and the evolution of ursemic paralysis 
differ according to the nature and the course of the neph- 
ritis of which it is the basic cause. Clinically one may 
distinguish two classes of cases according as the kidney 
lesion appears in old persons or children, or in adults, and 
again according as the nephritis be a chronic arterial, in- 
terstitial or subacute diffuse parenchymatous renal affection. 

"Ursemic paralysis in chronic nephritis is preceded by a 
few and insignificant prodromata and it ordinarily be- 
comes manifest by a sudden loss of consciousness, which 
precedes, or accompanies the hemiplegia. This apoplectic 
seizure often resembles very closely, so much so that one 
may be confused, a cerebral lesion of focal origin, and 
especially central cerebral hemorrhage. There is inertness 
of the limbs, insensibility to external irritations, sometimes 
conjugate deviation of the head and eyes. The inconti- 
nence of faeces and urine, the elevation of the temperature 
(Chantemesse and Tenneson) complete the similarity of the 
clinical picture. The deception is the easier, as usually 
the patient is a person advanced in life, where a vascular 
lesion would be expected. Nevertheless, in cases that 
have come to necropsy, as in that of Perret, no trace either 
of an area of softening or of hemorrhage will be detected. 
The arteries will be found normal. Such phenomena can 
only be attributed to an oedema of the brain substance, to 
the serum that dilates and fills the ventricles, and which 
oozes out in notable quantity on cutting into the meninges. 
Raymond jias published a case of ursemic paralysis sim- 



UREMIA. 283 

ulating a meningeal hemorrhage, yet where the necropsy 
only revealed an oedema of the cerebrum. Finally, there 
are cases where the paralysis simulates a paralysis following 
cerebral softening, with sudden setting in, as after em- 
bolism or thrombosis. 

" Uraemic paralysis in subacute nephritis assumes prefer- 
ably the hemiplegic form, but it is very different in its 
courses. The error in diagnosis is nearly always avoidable, 
as the disturbances of motion are readily made out. Here 
the paralysis supervenes as a phenomenon conjoined to a 
series of phenomena noted in children affected with scarlet 
fever. At times it has been observed in the nephritis of 
pregnancy, either before or after parturition. 

" Hemiplegia of ursemic origin is often partial, and as- 
sumes the brachio-crural type in one-half the cases. In 
the other portion it is accompanied by a facial paralysis 
which, on the contrary, is rarely found together with the 
monoplegic form (three times out of eleven). This facial 
paralysis does not differ in any way, except possibly by its 
rapid development, from that with cerebral hemorrhage. 
Isolated facial paralysis is more interesting, but it is very 
rare. 

"Usually the paralysis reaches its greatest intensity at 
the moment of its appearance, or it attains it the following 
day. It seems that incomplete paralysis is more frequent 
in chronic nephritis, while in all cases of sub acute ne- 
phritis it is complete. It is usually only complete for a short 
time, for it either is covered by the coma, ends in death or, 
another not less important feature, its variability, sets in. 

"Whether complete or not these paralyses are flaccid 
and remain thus during their evolution. However, con- 
tractures have been observed in seven cases; they were 
always noted as appearing early in the course of the case. 
These precocious contractures resemble those following 
hemiplegia due to cortical irritation, or a cerebral hemor- 



284 UROPOIETIC DISEASES. 

rhage with inundation of the ventricles. In five cases, 
death having occurred, the necropsy demonstrated the 
presence of abundant serous fluid in the meninges (Ray- 
mond) of infiltration of the brain substance by considerable 
oedema; or, a decided quantity of serum filling and dilat- 
ing the lateral ventricles. These contractures, in one case 
excepted, affected the paralyzed limbs. 

" Uraemic hemiplegia may persist without notable modi- 
fication until death ends the scene, or it may gradually 
decrease little by little, to disappear almost suddenly and 
to reappear. Its duration varies between a few hours to 
five days. Death generally ends the matter. 

"Disturbances of sensibility have been noticed in all 
uraemic states. Though sometimes unaffected in the 
majority of cases, it was diminished or abolished. It should 
not be forgotten that it is not the grade of the paralysis 
that regulates the sensibility, but the state of the intelli- 
gence. 

"The patellar reflex is usually abolished or decreased on 
the paralyzed side, yet may be normal or exaggerated. As 
to the pupils, they are generally myotis contracted. Con- 
jugate deviation was noted in a dozen cases associated with 
the hemiplegia. Ordinarily on the opposite side to that 
paralyzed ; it may be on the other. In three cases of this 
kind it was ascribed to contracture of the muscles of the 
neck of the paralyzed side. 

" Usually there is no modification of the temperature. 
In five cases only the elevation noticed appeared to be due 
to uraemic poisoning. In the others it was apparently a 
pulmonary complication to the convulsions, etc. On the 
contrary, a lowering of the temperature has never been 
detected. 

" The uraemic aphasia usually is noted as a pure motor 
aphasia, but it is probable that agraphia, together with 
blindness, often complicates motor aphasia and word deaf- 



UREMIA. 285 

ness. Ursemic aphasia is generally preceded by serious 
manifestations of urinary poisoning. It is most frequently 
associated with hemiplegia, which is either total or partial 
and generally right-sided. The aphasia may supervene 
independently of any motor disorder of the limbs or face. 
Three cases of sensorial aphasia without associated motor 
aphasia are reported. , 

u From a study of the case it seems that the appearance 
of a uraemic paralysis is of grave prognostic importance. 
Death follows in three-fifths of the cases in a period vary- 
ing from a few hours to a few days. 

" The diagnosis of ursemic paralyses is of extreme diffi- 
culty, especially of those occurring during the course of 
chronic nephritis. 

" After presenting all the theories offered to explain 
these paralyses, the necroscopical findings and the experi- 
mental facts are considered. Out of the thirty-nine cases 
a necropsy was done thirty-five times, and the clinical 
course of the case had been under observation. In twenty- 
nine of these there were twenty in which no focal lesion 
could be detected ; in four others there were such lesions. 

" In paralyses without macroscopic lesions, together 
with the constant lesion in the kidney, the most frequent 
fact is the cerebral oedema which has been noted in twenty 
cases. Exceptionally limited or predominating in one- 
half of the brain, this oedema, ordinarily diffuse, infiltrates 
the brain substance and exudes from the surface of the in- 
cision. It may be abundant and then there is an appreci- 
able dilation of the ventricles. Subarachnoid dropsy or 
infiltration of the pia mater may replace oedema of the 
cerebral substance. But in the great majority of the 
cases the yellowish serous fluid oozes out after incising the 
dura mater ; it infiltrates the pia mater as well as the sub- 
stance of the hemispheres. Often this oedema is accom- 
panied by a marked cerebral anaemia. Sometimes this 



286 UROPOIETIC DISEASES. 

anaemia may be present, with absence of any oedema or of 
any vascular lesions (Lancereax). (Bdematous infiltration 
may be lacking in other cases. Finally, it is well to re- 
member that- in old persons cerebral atheroma is quite fre- 
quent (Raymond). But there is no constant relation be- 
tween atheroma of the arteries of the brain and oedema. 

" In paralyses with macroscopic lesions the renal lesion 
is constant and the oedema frequent, but not constant ; 
more frequently foci of softening, haemorrhagic areas, etc., 
have been noted. 

" The experiments of Raymond and Arthaund to deter- 
mine that the local paralyses of uraemia are caused by vascu- 
lar modifications, to which a persistent anaemia is con- 
joined, thus giving rise to paralytic disturbances in the 
limbs, are but little conclusive. The efforts in attaching 
importance to the vascular disturbances of the cerebral 
circulation in old persons with paralyses of cortical origin 
may be viewed in the same manner. 

" Clinical facts bear witness to the susceptibility of the 
cerebral cortex to ursemic poisons. Recently Donetti has 
demonstrated experimentally the existence of cellular 
lesions peculiar to themselves, and which were most pro- 
nounced in the gray matter, varicose atrophy of the pro- 
longations of the nerve cells and of the neuroglia. These 
cellular lesions, still but little known, explain without 
doubt the abnormal duration of certain uraemic paralyses, 
and their slow restoration to the normal. How these 
local symptoms are produced by an uraemic intoxication 
can only be explained by the special susceptibility of the 
cerebral cortex to uraemic toxines, the circulatory modifi- 
cations depending either on atheroma or direct action 01 
these toxines on the arteries, partial oedema and finally in- 
dividual predisposition, congenital or acquired, of the 
psycho-motor zones." 

Aphasia of uraemic origin has been noticed by Rendu, 



UREMIA. 287 

Guyot and others. Rendu's case in the Hospital Necker 
seems to prove that the uraemic toxine may be limited to 
a particular area of cerebral tissue or to a general involve- 
ment, as was originally maintained. 

Uraemic insanity frequently develops and is often over- 
looked ; it occurs especially in chronic interstitial nephri- 
tis. The patient is restless, sleepless, talkative and noisy. 

In the uraemia of chronic Bright's with the headache, 
coma, convulsions, delirium, etc., there is usually rise 
of temperature ; the thermometer sometimes registers 108 
to 109 F. In acute cases a temperature of 103 or 104° 
F. for the first week is not uncommon. 

Arterial tension is one of the most frequent and grave 
phenomena noticed in uraemic conditions ; it accompanies 
most of the severe manifestations. When the uraemic con- 
ditions are prolonged, hypertrophy of the muscular coat of 
the arteries may develop, but the principal cause of the 
tension is undoubtedly due to irritation of the inner coat 
of the arteries by some toxic substance or substances in 
the blood which the kidney has failed to eliminate. 

Dyspnoea in Bright's disease may arise from many 
causes : From an accumulation of fluid in the pleural or 
abdominal cavities, oedema of the lungs, accumulation of 
bronchial secretions, etc., but the true uraemic dyspnoea 
is from another source, z. e., irritation and consequent 
poisoning of the respiratory centers from a substance con- 
tained in the circulation. This dyspnoea comes on insidi- 
ously, it is usually first noticed in the morning or after 
some unusual mental or physical exertion. At first the 
attacks are transitory and are frequently the first symptom 
to indicate the presence of Bright's disease. As the dis- 
ease progresses the paroxysms appear at more frequent in- 
tervals and are of longer duration. The patient is unable 
to lie down ; rales are absent in the bronchial tubes which 
differentiates it from bronchial asthma. After a time the 



288 UROPOIETIC DISEASES. 

seizures become continuous and agonizing ; the Cheyne- 
Stokes respiration may develop, and death finally result. 

Digestive disturbances are generally present. The 
breath frequently has the odor of urine. Vomiting may 
occur in both the acute and chronic forms of uraemia In 
the acute variety it may be produced either by the urea in 
the circulation or the hyperpyrexia ; in the more chronic 
form it may be distressing, sometimes lasting for days. 
It is especially noticeable in the morning, after taking 
food ; is usually accompanied by increased arterial tension, 
and is very exhausting and may terminate fatally. Diar- 
rhoea, pruritus, formication, numbness and pain in the 
joints, simulating rheumatism, are occasionally present. 

Diagnosis. — The diagnosis should always depend on 
the urinary analysis. When the patient is unconscious, he 
should be catheterized and the urine examined without de- 
lay. The symptoms of uraemia, objective and subjective, 
are usually all-sufficient to make a diagnosis, yet it is some- 
times impossible to differentiate the cerebral manifestations 
from those of cerebral haemorrhage, tumors and meningitis. 
All objective symptoms being equal, if the eyes converge 
to the same point, the probable diagnosis will be apoplexy, 
and not uraemic coma. Epileptic convulsions simulate 
very closely those of uraemia, and albumen may even be 
present in the urine, but only during and immediately 
after an attack ; in uraemia it is persistent. Poisoning by 
narcotics also simulates uraemic conditions. In opium 
poisoning the respiration is slow and stertorous ; in 
uraemia it is asthmatic and hissing. 

Prognosis. — The prognosis is always grave. When 
occurring during acute nephritis, the patient usually re- 
covers. In chronic parenchymatous nephritis it is a symp- 
tom of approaching death, though relief may sometimes 
be given for a considerable period. In chronic interstitial 
nephritis it indicates impending death. 



URAEMIA. 289 

Treatment. — The remedy indicated by the totality of 
the symptoms should be administered. 

Ammonium carbonicum : In the non-reactive state of 
uraemia, stupid in action, grasping at flocks, face and lips 
bluish, rattling as of large bubbles in the lungs. 

Arsenicum album : Uraemia, with great anxiety, restless- 
ness and sinking of the vital forces, with a feeling that it 
is useless to take medicine and that they are about to die ; 
dyspnoea, either cardiac with palpitation, or due to oedema 
of the lungs, worse at night and when lying on the back ; 
dyspnoea aggravated on lying down, especially recurring at 
12 P. M., and relieved by expectoration. 

Cannabis Indicus : Uraemia, with severe headache, sen- 
sation as if the vertex was opening and closing, associated 
with delusion of time and space ; objects seem a long dis- 
tance off ; forget what they intend to say or do. 

Cantharides : Headache, delirium, coma, with suppres- 
sion of urine. This remedy frequently increases the flow 
of urine and prevents convulsions. 

Carbolic acidum : Great fullness of the cerebral vessels, 
sensation of a band around the head, headache, vertigo, 
clonic convulsions, coma, great languor of mind and 
body. 

Cicuta virosa : Convulsions, with twitching of individ- 
ual muscles. 

Cuprum arsenicum : Uraemic convulsions. Goodno 
considers this remedy in the second or third decimal tritu- 
ration almost infallible. 

Glonoin : Uraemic dyspnoea, uraemic convulsions, froth- 
ing at the mouth, pulse full and hard, unconscious, with 
thumbs clenched into the palms. 

Helleborus niger : Blunting of the general sensibili- 
ties ; pupils dilated and do not react to light, or while see- 
ing do not seem to regard the objects seen ; violent pain 
in the head, especially in the occiput ; face swollen and 
19 



290 UROPOIETIC DISEASES. 

puffy, nausea, vomiting, absence of thirst ; convulsions, 
with cold extremities ; urine scanty or suppressed. 

Hydrocyanic acidum : Ursemic convulsions, withdrawing 
backward of the head, respiration irregular, gasping, great 
cardiac distress, coldness and blueness of the extremities. 

Opium : Ursemic coma and convulsions. 

For more complete symptomatology and other remedies 
see chapter on therapeutics. 

In conjunction with the indicated remedy the adoption 
of physiological means is often imperative. The diet re- 
quires careful consideration. Milk, cheese, eggs and boiled 
meats are especially advised. Soups, all indigestible foods 
and all nutriment which tends to increase intestinal fermen- 
tation must be interdicted. Intestinal putrefaction should 
be prevented by the administration of Charcoal, Iodoform, 
Naphthalin, Salicylate or Subnitrate of Bismuth. These 
remedies have given much relief in ursemic conditions. 
Hot baths are beneficial in stimulating the excretory func- 
tion of the skin. When profuse sweating is desired, Pilo- 
carpin may be administered if there is only simple hyper- 
trophy of the heart muscle and no other cardiac lesion, 
though it is a heart depresant and its administra- 
tion has frequently been attended with disastrous results. 
Children are proportionately more tolerant of the drug 
than adults. From a physiological stand-point, hot dry 
baths should be of service, as the dry air is exchanged in the 
lungs for that which is laden with moisture. Profuse per- 
spiration may be induced by hot vapor baths or the admin- 
istration of Jaborandi. These methods simply diminish 
the amount of water discharged as urine and do not elimi- 
nate the toxic materials from the blood ; they often pro- 
duce harmful results. Bleeding should be resorted to in 
threatening and dangerous ursemia, in conjunction with 
the inhalation of oxygen. The removal of a portion of 
blood, and the transfusion of an equal quantity of saline 



UREMIA. 291 

solution, by eliminating a certain amount of urea and di- 
luting the remainder of the blood, has given immediate 
relief. 

When arterial tension is present, most authorities, at 
the present time, advise the administration of Glonoin, 
Chloral hydrate or Morphia, as indicated by their physio- 
logical action, to relieve the tension, and, for the time be- 
ing, remove the strain upon the system. 

Revulsions, such as the wet or dry cup, leeches and 
cutaneous friction, stimulate the nervous system by re- 
flexes from cutaneous irritation and often quicken the 
renal circulation and increase the functional activity of the 
kidneys. Digitalis is frequently of benefit, but it must be 
used with caution, not only as to dose, but the time of its 
administration. It is contra-indicated when the permea- 
bility of the kidney has been greatly diminished, as the 
drug is then retained in the blood and increases the general 
toxicity. It is indicated when there is cardiac weakness 
without marked diminution in the permeability of the kid- 
ney. In this variety of ursemia it increases the quantity 
of urine voided and gives much relief. Bouchard has 
produced marked diureses with great benefit by the sub- 
cutaneous injection of urea. 

Free purgation has sometimes been useful. When the 
patient is unconscious, this is best produced by placing 
a drop of Croton Oil on the finger and applying it to the 
back of the tongue ; when able to take medicine, Bla- 
terium, in ^o to yi grain doses every four hours, or an 
ounce of Magnesium sulphate dissolved in an ounce and 
a half of water, may be given early in the morning, the 
patient taking no fluids for twelve hours before it, and not 
until six hours afterwards, have acted satisfactorily. 

Theoretically, purgation removes the water from the 
system but it does not diminish the amount of urea. 
Vomiting may do the same, it also lowers arterial tension 



292 UROPOIETIC DISEASES. 

and diminishes renal secretion. Experiments demonstrate 
that the toxicity of the urine diminishes during purga- 
tion because some substance, probably one of the unknown 
organic substances, is removed from the blood, which, if al- 
lowed to remain, might produce uraemic manifestations. 
Bromide of soda is often useful in the control of convul- 
sive symptoms, but the potassium salts should never be 
used as they increase the toxicity of the blood. 



CHAPTER XXVI. 

ABNORMAL STATES OF THE URINE CLASSED 
AS DISTINCTIVE CONDITIONS. 

ACETONURIA. 

This term signifies the presence of acetone in the 
urine. Jakosh is of the opinion that it is always pres- 
ent, in minute quantities, in normal urine, while others 
claim that it only appears in health after alcohol or meats 
have been ingested to excess. It is present in conditions 
accompanied by rise in temperature, especially measles, 
scarlet fever, smallpox, pneumonia, Bright's disease, car- 
cinoma, mental excitement and particularly in diabetes 
mellitus. By auto-intoxication, it may produce restless- 
ness, mental excitement and delirium. 

Treatment. — This must be directed to the removal of 
the cause. 

ALBUMINURIA. 

Within recent years the subject of albuminuria has re- 
ceived special consideration. Some observers have asserted 
that a physiological or natural albuminuria sometimes ex- 
isted, dependent upon a perverted function of the sympa- 
thetic nerves, but the researches made by numerous careful 
investigators apparently demonstrate that albuminuria al- 
ways indicates the presence of a pathological lesion, transi- 
tory or permanent, of some part of the genito-urinary 
tract. Post-mortem examinations of the kidneys, where 
no clinical history has given evidence of renal disease, 



294 ■ UROPOIETIC DISEASES. 

when carefully and minutely conducted, rarely fail to dem- 
onstrate some gross or microscopic lesions. Hence, who 
can say that the so-called functional physiological or transi- 
tory albuminuria in a given case is not due to some of 
these insignificant pathological lesions which, under ordi- 
nary conditions, give no clinical evidence of their exist- 
ence. 

The albuminuria of renal origin and the pathological 
lesions producing many so-called functional or physiolog- 
ical albuminuria, have received proper consideration 
in the various chapters of this book. The extrarenal 
causes of the presence of albumen in the urine are 
legion, and must always receive particular considera- 
tion in formulating the prognosis of any given case. 
In lithsemic or oxaluric conditions the crystals of uric 
acid or oxalate of lime voided with the urine some- 
times irritate and scratch the mucous membrane of 
the uropoietic system, exciting an albuminous exudate; 
abrasions, congestions, inflammation of all grades, and ul- 
ceration of the mucous membrane of the genito-urinary 
tract, cause an albuminois exudate of more or less magni- 
tude. In pyuria, hematuria, hsemoglobinuria, etc., albu- 
minuria can always be demonstrated. Another and very 
frequently overlooked source of albumen in the urine in 
the male is the presence of the normal or pathological 
secretions from the prostate and seminal vesicles ; it is 
here usually more noticeable in the morning urine. In 
the female, the urine is often contaminated with albu- 
minous secretions from the genital tract. 

Treatment. — This must be directed to the removal of 
the cause, with the administration of remedies as symptom- 
atically indicated. 

ALKAPTONURIA. 

This term has been applied when the urine appears 
normal on being voided, but if kept for a few hours it 



BACTERIURIA. 295 

becomes dark or black, due to the presence of hydro- 
quinone. The condition has no clinical significance, and 
is generally due to the ingestion of Salol, Carbolic acid, 
Quinine, Resorcin, Uva ursi, etc. 

BACTERIURIA. 

This name has been given to the condition where 
large numbers of bacteria are voided in the urine. It was 
first described by Roberts in 1881, and later was especially 
studied by Ultzman. It frequently passes unnoticed, or, 
if recognized, receives but little attention. 

Etiology. — Bacteria may enter the bladder either from 
within, from the neighboring organs, or from without ; in 
other words, infection or auto-infection. In the majority 
of cases bacteriuria is due to auto-infection, either di- 
rectly from the intestines by contiguity or indirectly by 
absorption from the intestines into the circulation and be- 
ing carried in the blood stream to the kidney and allowed 
to percolate through it with the urine. (The experiments 
of Baumgarten and others have proved beyond question 
that the kidneys have the power or physiological action to 
excrete micro-organisms.) Bacteriuria is believed to 
happen frequently when from any cause there is an abrasion 
in the mucous membrane of the rectum or intestines. 
When occurring directly by contiguity of tissue, it may be 
due to perforation of a prostatic abscess, either into both 
the rectum and the urethra or into the rectum alone. In 
either way the bacteria reach the posterior urethra and 
then travel back to the bladder. In bacterial vesiculitis 
the bacilli coli communi sometimes pass into the bladder 
by direct communication; they may contaminate the urine 
as it passes through the prostatic urethra ; or travel back 
from the urethra into the bladder; a few find their way 
into the urinary stream from the lymphatics which have 
absorbed them in the intestines. Direct infection through 



296 UROPOIETIC DISEASES. 

the urethra may occur, bacteria being carried by unclean 
instruments, or where the canal previous to instrumenta- 
tion has contained a bacterial nidus. Bacteria are some- 
times inhaled and eliminated by the kidneys, as demon- 
strated by the urine of medical students when engaged in 
dissecting. This condition has also been frequently met 
with in chronic malaria. 

Pathological Anatomy. — Bacteriuria is remarkable in 
uncomplicated cases for the continued healthy condition of 
the mucous membrane of the urinary tract, though 
patients suffering with bacteriuria are especially liable to 
cystitis if exposed to unfavorable influences. 

Clinical History. — The symptomatic history is very 
meagre. The urine when voided is opalescent, cloudy 
and often offensive. The cloudiness is not changed by 
boiling, acidulation, or filtration with the ordinary filter 
paper ; but if a Pasteur filter is used, the urine becomes 
clear ; it may also be cleared by shaking it with Calcined 
magnesia or Carbonate of barium before filtration. The 
urine is always acid or neutral in reaction, never alkaline 
unless associated with some other condition. The bacteria 
and cocci are essentially those of intestinal fermentation. 
The bacilli coli communi predominate. The micro- 
scopic investigation can be made by adding a drop of 
aniline violet to a drop of urine on a glass slide, passing it 
slowly over an alcohol flame once or twice and allowing it 
to cool, and then examining it with an oil-immersion 
lens. 

Bacteriuria may be acute, subacute or chronic, very 
severe or mild. The first symptom noticed in this disease 
is a burning pain upon urination, which occurs only or 
mostly upon evacuation of the last few drops ; this may reach 
a point of tenesmus, with dropping of urine and increased 
desire of urination even to incontinence, accompanied 
with pains in the region of one or both kidneys, which 



BACTERIURIA. 297 

are often described as backache, but which upon close 
questioning and examination can be localized in the 
renal region. This condition suddenly attacks individuals 
whose previous health has been good, and happens without 
any definite etiological basis. Exposure to cold, long re- 
tention of urine, and habitual constipation play some part. 

In some cases the patients seek medical aid only on ac- 
count of the bad-smelling urine. If this urine is centri- 
fuged or left to sediment, the deposit is found to be made 
up of the bacterium coli and epithelia ; in other words, the 
absence of evidence of any other bladder or kidney disease. 
In some cases this condition is followed by disease of these 
organs or the abdominal viscera. The patients are gen- 
erally slender, pale, moderately nourished individuals who 
do not feel sick ; in some cases, at the time of the at- 
tack, they feel very sick. The term bacteriuria is used only 
for such cases in which, in healthy individuals without 
any clinical evidence of inflammatory processes in the 
genito-urinary tract, and without definite cause, micro- 
organisms are present in the urine as evacuated and give 
rise to symptoms of disease. 

Bacteriuria is frequently associated with disease of the 
seminal vesicles and prostate. In the author's experience 
both sexes are equally affected. It is very liable to recur, 
and is only cured by perseverance, careful therapy and 
hygiene. 

Prognosis is always doubtful. While in some instances 
bacteriuria appears to be harmless, still it is always 
very difficult to rid the urine of bacteria and keep it 
absolutely free. The disease, therefore, is always to be 
looked upon as serious. Bacteriuria, pure and simple, 
often disappears without any special medicinal care. 

Treatment. — The remedies most frequently indicated 
are Nitric, Muriatic or Benzoic acids ; physiologically, 
Salol, Naphthlin, Sodium benzoids, Salicylic acid, Char- 



298 UROPOIETIC DISEASES. 

coal, Oil of Wintergreen or Eucalyptus. When the 
bacteria have been introduced from without, the various 
antiseptic douches used for the urethra and bladder will be 
required, and may be all sufficient; these are Potassium 
permanganate i to 2,000 to 1 to 10,000, Argentum nitri- 
cum 1 to 4,000 to 1 to 16,000, Hydrargyri bi-chloride, 1 
to 10,000 to 1 to 20,000, Carbolic acid 1 to 500, normal 
Quinine sulphate, one grain to the ounce, or Borolyptol 
one part to four to eight of warm water. To remove all 
of the residual bacterial urine, the bladder should be 
catheterized every three hours for several days. In many 
cas.es good results are only procured when for some time 
the bladder is washed thrice daily after catheterization. 
When bacteriuria is the result of lesions in the mucous 
membrane of the rectum or intestines, flushing of the 
rectum and colon with two quarts of soap and water night 
and morning will materially assisted in the cure, by re- 
moving and reducing the number of bacteria in the 
intestines. In all obscure cases the seminal vesicles must 
be interrogated, and if diseased must receive proper treat- 
ment. 

CHYEURIA. 

This name is applied to a condition of the urine when 
it presents a milky or opalescent appearance due to the 
presence of minute particles of fat in suspension. 

Etiology. — It is caused by a parasite called the filaria 
sanguinis hominis, which is about one-seventieth of an 
inch in length and the diameter of a red blood corpuscle; 
they are found in the blood stream. The larger worm, 
the filaria Bancrofti, is occasionally present in the lym- 
phatics, and often obstructs the thoracic duct. There is 
also a non-parasitic form of the disease, caused by the ob- 
struction of the thoracic duct in some other manner. 

Clinical History. — This disease is endemic in the East 



CHYLURIA. 299 

and West Indies, Brazil, Cuba, China, Australia, and most 
tropical and sub-tropical climates. It is occasionally met 
with in the temperate zone, in people who have con- 
tracted it abroad or have been poisoned by mosquitoes 
which were brought in ship cargoes from these infected 
regions. The parasitic form of the disease is due to the 
blocking of the lymphatics 03' minute micro-organisms', 
causing the contents of the lacteals and intestinal absorb- 
ents to escape through some accidental urinary or lym- 
phatic communication. The flliaria sanguinis hominis is 
peculiar, in the fact that it can be found in the chyliferous 
urine at any time, but more particularly after eating. In 
the blood, however, they are present only during the night 
or sleeping hours. It is said that the blood of one in 
every ten Chinamen contains these micro-organisms, but 
no symptoms are produced unless the parasite becomes 
diseased, when the general health will suffer, i. e., 
progressive debility, lassitude, emaciation, etc. The patients, 
however, usually die from some intercurrent disease. The 
urine is characteristic, but often all evidence of its 
chyliferous character may disappear for months or years ; 
it is opalescent, and, often of a reddish cast, from the 
admixture of blood corpuscles. Its specific gravity 
varies from 1,007 to 1,020. From 80 to 100 ounces 
are voided daily, the increase being probably due to the 
addition of the chyle and lympathic products. The amount 
of fat varies from 2-10 to 2 per cent.; it increases after 
meals, exercise, and sometimes varies with the position of 
the body. When allowed to stand the urine behaves 
something like blood, thickening, and then separating. into 
a semi-solid and a fluid portion ; the micro-organisms are 
found in the coagulum. The urine has the odor of whey, 
and contains albumen, fibrin, and blood corpuscles. 

Sometimes chyliferous urine coagulates in the pelvis of 
the kidney and the bladder, causing nephritic colic and 



300 UROPOIETIC DISEASES. 

cystitis; when this occurs, a catheter must be introduced 
into the bladder, and a solution of Sodium bicarbonate 
freely introduced to break up the mass, and facilitate its 
discharge. 

CYSTINURIA. 

This is a rare condition ; its chief interest centres in the 
fact that it is the cause of the cystin calculi. 

Etiology. — The latest researches point to a relationship 
between cystinuria and a micro-organism of intestinal 
origin. 

Clinical History. — The urine may contain cystin inter- 
mittently for years without producing any special impair- 
ment of the health. The urine, when voided, has an odor 
resembling Orris root ; it decomposes rapidly and, on 
standing, a greasy scum forms on its surface ; when fresh 
it has a yellow-green color and may be acid or neutral 
in reaction. 

GLYCOSURIA. 

The urine of this class contains a varying amount of 
sugar when voided and is indicative of diabetes mellitus. 

GLOBUEINURIA. 

Globulin is generally present in the urine of Brighitic 
subjects, in acute cases and in amyloid nephritis it may 
exceed the serum albumen present. It is also found in the 
urine of those suffering from acute catarrhal cystitis and 
in certain digestive disorders. 

DIACETURIA, 

The urine in this condition, contains diacetic acid. It 
is always pathological. When it occurs during febrile 
diseases in children it is unimportant, but in the adult suf- 



HEMATURIA. 301 

fering with diabetes it indicates the approach of coma and 
a fatal termination. By auto-intoxication, it produces 
dyspnoea, nausea, vomiting, jactitation, etc., terminating 
in coma and death. 



HEMATURIA. 

Blood alone or combined with other foreign substances 
sometimes appears in the urine, and constitutes the condi- 
tion described as haematuria. The blood may be from any 
part of the genito-urinary tract and depend upon disease, 
follow an injury or the administration of certain drugs, 
i. e., Quinine, Turpentine, etc. When the blood comes from 
the kidney it is intimately mixed with the urine and the 
perceutage of albumen present is large. The urine will 
contain blood corpuscles, renal epithelium, and occasion- 
ally casts, the specific gravity is below normal, the reaction 
acid and on standing a coffee-brown precipitate deposits. 
The clots in renal haematuria are rounded, rod-like and 
slender, being compressed to the size and form of the 
ureter in passing through it. 

When the blood is from the bladder the clots are very 
large and irregular, and the relative percentage of blood in 
the urine increases as the bladder empties itself. The blood 
is bright but not intimately mixed with the urine, which is 
generally alkaline in reaction from an associated cystitis. 
When the blood is from the prostatic portion of the urethra 
the clots are leech-like or ovoid in form, and the percent- 
age of blood is usually greatest at the commencement of 
the act of micturition. If the haemorrhage is from the 
prostatic urethra and profuse blood may, between the 
acts of urination, pass back into the bladder and mix 
with the urine ; in other cases there will be only a drop of 
blood expelled at the end of the act. When the blood is 
from the anterior urethra, the clots assume the shape of 



302 UROPOIETIC DISEASES. 

this portion of the canal, and blood will ooze from the 
meatus between the acts of micturition.' The exact location 
of the haemorrhage along the urinary tract must be deter- 
mined by the urethroscope, cystoscope and the clinical 
history of the individual causes. 

Treatment. — Cantharides : Haematuria of inflammatory 
origin with vescical tenesmus. 

Crotalus : Haematuria from blood degeneration, the uri- 
nary deposit looking like charred straw and containing 
degenerated blood cells and fibrin. 

Equisetum : Haematuria and slight tenesmus, with ten- 
derness and soreness over the region of the bladder, not 
relieved by urination. 

Ipecac : Hsematuria, blood from the kidneys, accom- 
panied by nausea, oppression of the chest, cutting pain 
in the abdomen and hard breathing. 

Lachesis : Hsematuria, blood in the urine looks black, is 
the result of blood degeneration. 

Nux vomica : Hsematuria with frequent and painful 
micturition. 

Terebinth: Hsematuria, urine smoky, turbid, with a 
sediment like coffee grounds. 

Thlapsi bursi pastoris : Haeinaturia, blood bright or dark 
color, urine also containing uric acid crystals and pus. 
The quantity of blood is increased by motion and accom- 
panied with pain in the kidney region. 

Rest in the recumbent position with a liquid diet com- 
posed of milk broths and dilutants is very essential. If 
the haemorrhage is profuse and clots accumulate in the 
bladder, causing retention of urine with restlessness, 
pain, tenesmus, anxiety, etc., catherization will be indi- 
cated and possibly the clots will need removal by suction 
with a syringe. After the bladder is evacuated it should 
be douched with a warm solution of Nitrate of silver i to 
2000, Carbolic acid i to 300, Kmesty's aqueous Hydrastis 



HEMOGLOBINURIA. 303 

canadensis, one ounce to the pint, or a 5 per cent, solution 
of Antipyrin. If the bleeding is excessive, it is often ad- 
visable to institute continuous catherization for a few days. 
In others, Iodiform suppositories act kindly, particularly 
when the haemorrhage is of tubercular origin. Hsematuria 
often yields quickly to the administration of ten grains 
each of Calomel and Pulv. • Jalap taken at one dose. 
When catherization is impossible perineal cystotomy fol- 
lowed by continuous drainage will often be required. In 
all cases the cause must be searched for and if possible 
removed. 

HEMOGLOBINURIA. 

This condition is more common among males than 
females, and occurs generally between the twentieth and 
the fiftieth years. Malaria, certain infectious diseases, 
colds, burns and some forms of poisoning, such as over- 
doses of Quinine, are undoubtedly the important exciting 
causes. It also appears as an intermittent idiopathic con- 
dition. 

Clinical History. — The urine is characterized by the 
presence of the coloring matters, and the absence of the 
cellular elements of the blood. The coloring matters im- 
part a dark red or smoky appearance to the urine and 
a chocolate color to the sediment. The specific gravity 
varies from 1015 to 1030, the reaction acid or faintly 
alkaline, the urea increased and tbe globulin present gives 
the characteristic reaction for albumen. The volume of 
urine discharged daily may be a little augmented. The 
sediment is composed of amorphous granular matter, 
crystals of haematin, dark granules and hyline casts, often 
composed of haemoglobin, and crystals of oxalate of lime, 
uric acid and urates. The chlorides are deficient while 
the phosphates and sulphates are increased. The clinical 
symptoms commence with a chill, the result of exposure of 



304 UROPOIETIC DISEASES. 

the body to a lowered temperature. The chill is sometimes 
preceded by colicky pains in the umbilicus. The tem- 
perature often falls to 96 F. with the chill, and gradually 
rises to normal as it subsides. The chill is followed by 
nausea, vomiting, general pain through the back and the 
extremities, and retraction of the testes, with exhaustion, 
followed by headache, thirst, comatose state and possibly 
jaundice or urticaria. Pressure over the region of the 
kidney may demonstrate an over-sensitive condition. The 
attack may terminate in a few hours or continue for a 
number of days. 

Prognosis is uncertain. Exposure to cold may at any 
time cause a return of the clinical manifestations. It 
often becomes chronic and recurrent and may terminate in 
a nephritic lesion. 

Treatment. — Ferrum phos., Kali chlor. Phosphorus 
and Crotalus are often indicated in haemoglobinuria, and 
give very satisfactory results. Quinine, in large doses, some- 
times acts kindly, though it often seems to aggravate the 
condition. Morphine, Epsom salts and Turpentine have 
had their advocates. Irritating and alcoholic foods must 
be avoided, and a diet similar to that advised for acute 
nephritis, with rest in bed and protection from cold and 
dampness recommended during the attack. 

HYDRIOTHIONURIA. 

The presence of sulphuretted hydrogen in the urine con- 
stitutes this condition. It may be due to absorption from 
the intestines or to some abnormal communication between 
the intestines and the urinary tract. 

INDICANURIA. 

Urine containing an excess of indican suggests excessive 
albuminous putrefaction in some portion of the system 
and is a frequent concomitant of intestinal disorders, espe- 



INOSITURIA. 305 

cially those of the small intestine. It is also present in 
disorders of the sexual functions of men, Addisons's dis- 
ease, cholera, carcinoma, etc. 

INOSITURIA. 

Muscle sugar may be found in the urine of those suffer- 
ing with diabetes mellitus, typhus, phthisis, syphilis, etc. 
There is associated malaise, loss of flesh, general pain, pain 
in the limbs and polyuria. 

LACTOSURIA. 

When the urine voided contains sugar of milk, the con- 
dition is termed lactosuria. It may happen after confine- 
ment, particularly as the flow of milk is being established, 
and often for a few days after the child is weaned. 

L^VULOSURIA. 

In this condition the urine contains lsevelose. It has 
been found in diabetic cases, though it is usually the result 
of over-ingestion of cane sugar and certain kinds of fruit 
sugars. 

UPURIA. 

When the urine contains more than two grains of fat to 
the gallon, which is considered a normal amount, the con- 
dition of lipuria is established. It may be the result of 
excessive ingestion of fatty food or be due to pathological 
causes and appear as a concomitant of renal or hepatic 
lesions, etc., and during convalesence from fractures. 

MELANURIA. 

Urine which is black when voided is pathological and is 
due to the presence of a black pigment. It occurs partic- 
ularly in those suffering from pigmented tumors, 
especially melanotic growths and sarcoma. It also presents 
in some who have had repeated attacks of intermittent 
fever. 

20 



306 TJROPOIETIC DISEASES. 

OXALURIA. 

Etiology. — At best it is an obscure condition ; it may 
be the result of either carbohydrate or nitrogenous metab- 
olism. Rencke gives the following conclusion as to the 
cause as follows : Oxaluria accompanies the lighter or 
severe forms of illness ; has its proximate cause in im- 
peded metamorphosis, i. e., in an insufficient activity of 
that stage of oxidation which changes oxalic acid into car- 
bonic acid. Oxalic acid has its chief source in the azotized 
constituents of the blood and food ; hence, everything 
which retards the metamorphosis of these constituents gives 
rise to oxaluria. Such retardation of the metamorphosis of 
azotized elements of the blood may be determined by the 
following causes : Excessive use of azotized, saccharine 
and starchy foods, insufficiency of the red blood corpuscles, 
entailing diminished oxidation, insufficient access to pure 
fresh air, organic lesions which in any way impede respi- 
ration or circulation, conditions of the nervous system 
entailing depression. Excess of alkaline bases in the 
blood. 

Clinical History. — Whenever there is continuously an 
abundance of the oxalate of lime crystals in the urine, 
the condition is designated as oxaluria and was first de- 
scribed by Golding Bird in 1842. This name should, 
however, not be used unless the oxalate crystals are 
present in abundance, as they are normally found in the 
urine, and are slightly increased after the ingestion of cer- 
tain foods. The urine is usually slightly clouded by 
mucus, and the crystals are, as a rule, only noticed on mi- 
croscopical examination. 

There are two varieties of oxaluria. In the first class 
the urine is concentrated, dark in color, over-acid in re- 
action and of high specific gravity, due to the abundance 
of uric acid and urates ; the patients are hypochrondiacal, 



OXALURIA. 307 

melancholy, sleepless aad deficient in mental vigor ; there 
are also digestive disturbances with imperfect assimilation 
of food, flatulence, loss of strength and great emaciation, 
accompanied by neuralgic pains in various parts of the 
body. In the second class the urine has the same char- 
acteristics, the neuralgic pains are more marked, especially 
in the back and in the extremities, accompanied with great 
loss of strength, but without emaciation as in the former 
variety ; boils and small abscesses develop in various 
parts of the body. 

Treatment. — The remedies most frequently indicated 
are Nitro-muriatic acid, Senna, Oxalic acid, Kali sulph., 
and Berberis. 

Mitchell advises five to seven drop doses of dilute 
nitrohydrochloric acid, freshly prepared, well diluted, 
taken three times daily, especially for young men with 
oxaluria complaining of malaise, great repugnance to 
mental and physical exercise with depressien of spirits and 
Lysidine, ten drops of a 50 per cent, solution three times daily 
when lumbar pains, irritability of the bladder irregular 
action of the heart and nervous symptoms predominate. 

The diet must be carefully regulated. It should be 
plain and composed of stale bread, food rich in phospates, 
as fish roe, calves' and sheeps' brains, Hudson's food, etc. 
An absolute beef and hot water diet has been of the 
greatest benefit, and many have been cured by it alone. 
Sugar, tea and coffee should be interdicted, as well as 
vegetables and drugs containing an abundance of oxa- 
lates. Alcohol, apples, bananas, rhubarb and tomatoes, as 
a rule, should be avoided ; when stimulants are required, 
brandy, whiskey, red wine and bitter ale may be allowed. 
Hard water should be avoided and soft or distilled water 
advised. A residence in the mountains or at the seaside, 
according to the individuality of the patient, should be 
recommended. 



308 UROPOIETIC DISEASES. 



PHOSPHATURIA. 

This means an increase of phosphates in the urine. It is 
divided into three classes — true, functional and secondary. 
In true phosphaturia there is a persistent and abnormal 
accession in the earthy and alkaline phosphates of a 
sterile urine, due to some general condition which causes 
excessive metamorphosis of the nerve matter, or to 
change in the nutrition due to irritation of the nerve 
centres. It also precedes or accompanies debilitating 
diseases, i. e., tuberculosis, cancer, diabetes, etc. The 
quantity of phosphoric acid daily eliminated by the 
kidneys in true phosphaturia is increased to some extent 
over the normal amount, and varies with the cause 
and duration of the condition. The quantity of urine 
secreted daily is augmented, micturition is increased in 
frequency and accompanied by a little vesical irritability ; 
it may be acid or alkaline in reaction. The patients 
are hypochondriacal, irritable and emotional. Vertigo is 
sometimes complained of, with numbness and weariness 
in the limbs and back. The gait is unsteady, the hands 
tremble, the tongue is pale and flabby, and constipation is 
usually present. 

In functional phosphaturia there is a transitory deposit 
of earthy phosphates, which sometimes occurs in those who 
are weak and run down. The urine may be acid or alka- 
line, the daily quantity of phosphates excreted being 
normal in amount. It is caused by the ingestion of 
sugar, of over-acid fruits, champagne, etc. ; it is also the re- 
sult of over-indulgence in venery or perverted sexual 
habits. There is no excess of phosphates, but the alkalinity 
of the urine causes the normal and amorphous phosphates 
to deposit, and produce turbidity. Beyond this cloudiness 
there are but few symptoms, except a slight depression 
of spirits and poor assimilation of food. 



PYURIA. 309 

In chronic catarrhal prostatitis and prostatorrhoea, the 
urine often contains an excess of phosphates, due to 
contamination with the excessive prostatic fluid ; the con- 
dition is not in any way dependent upon that usually 
ascribed to phosphaturia. 

Secondary phosphaturia is dependent upon inflamma- 
tory changes in the bladder or pelvis of the kidney, which 
cause decomposition of the urine, the urea being chemically 
broken up; the resulting carbonate of ammonia combines 
with the magnesium phosphate and forms ammoniaco- 
magnesium phosphate. The phosphates may be dis- 
charged with the urine as white masses mixed with mucus, 
or they may be deposited on the inflamed mucous mem- 
brane. 

Treatment. — Phosphoric acid in the potencies has given 
excellent results in both functional and true phos- 
phaturia. When the turbidity of the urine continues and 
does not respond to the indicated remedy, teaspoonful 
doses of Rulfe's mixture, which is composed of Boric acid, 
grains 120 ; Glycerine, ounces 1, and warm water to make 
8 ounces. A teaspoonful of the Acid phosphates in ^ glass 
of water after meals; Boric acid, grains v., or Urotropin, 
grains viiss, may act satisfactorily. Mitchell recommends 
one-half ounce doses of the wine of Phospho-glycerate of 
lime with the meals. When of the secondary variety, the 
treatment will call for remedies indicated by the catarrhal 
condition which produces it. 

The diet must be nutritious and easily assimilated, 
hard water avoided, the sleep and exercise regulated, and 
out-of-door employment commended. 



When pus derived from any part of the genito-urinary 
tract, is voided with the urine, the condition is called 
pyuria. Whenever pus is present, albumen will be found 



310 UROPOIETIC DISEASES. 

in a relative proportion. When the pus is the result of 
kidney suppuration, the relative quantity of albumen will 
be large, casts are frequently present and the urine may be 
acid or alkaline in reaction. If acid, the deposit will appear 
flocculent ; if alkaline, it will be ropy. When the pus is 
from the pelvis of the kidney, the urine is usually acid in 
reaction and contains a flocculent deposit ; it may be alka- 
line ; pus plugs and tailed epithelium will be discovered with 
the microscope. When the pus is from the bladder, the uri- 
nary sediment will be thick and ropy, the reaction alka- 
line, and the urine will contain large numbers of triple 
phosphates, bacteria, bladder epithelia and swollen pus 
corpuscles, and the last few drops voided will be very tur- 
bid. When the pus is from the prostatic portion of the 
urethra, the urine will be acid in reaction, the pus sedi- 
ment shreddy and frequently streaked with blood ; the 
first portion of the urine passed may be cloudy and the lat- 
ter portion clear. Micturition is usually painful. When 
the pus is of urethral origin, it will usually be noticed 
oozing from the meatus between the acts of micturition, 
and the last portion of the urine will be clear and free 
from pus, and always acid in reaction. 

Treatment. — This varies with the case and may require 
local surgical or constitutional methods. 

POLYURIA. 

This is defined as a condition in which there is an ab- 
normal secretion of urine of low specific gravity, free from 
sugar and albumen, and accompanied with great thirst. 
Willis divides the excessive secretion of urine into two 
groups : Hydruria, in which the solid constituents are de- 
ficient, and azoturia, in which there is an excess of urea. 
Fenwick believes that polyuria may be of both renal and 
extrarenal origin. He lays great stress on the fact of the 
persistent or transitory nature of the excess. He has col- 



URIC ACIDURIA. 311 

laborated a table which gives all the causes of polyuria and 
is as follows : 

No sugar, but extreme !„.,,. . ., 
thirst ; urea increased. J Diabetes insipidus. 

.,, mo „ .-v, „„„*«, u „i. f Chronic Bright's disease, such as gran- 
Persistent Alb S£5£ r^^f^S J ular kidney, amyloid kidney and ad- 
excess of J W 'J h ° Ut PUS orresidual \ vanced scrofulous or syphilitic affec- 
urine. urine. ^ tions 

tvtv, „it,„ m ^ -u„f ^,-fi, ^ f Back renal pressure, from ureteral twist 
SshS?^SU \ or prostatic atony, or direct renal irri- 

sidual urine. ^ tation of prostatic origin. 

f From sexual excesses or debility, without inflammation. 
Transient excess | 
of urine, usually •{ Dietetic idiosyncrasy, i. e., tea, beer, etc. 
diurnal. 

[_ Hypochondriasis, hysteria, nervousness. 

Treatment. — Nocturnal and diurnal polyuria, Scilla 
maritima ; nocturnal polyuria, Phosphoric acid ; diurnal 
polyuria, Ignatia amara, Murex purpurea. When from 
high arterial tension, Glonoin ; from interstitial nephritis, 
Nitric acid. Diet and hygiene will depend upon the 
cause, etc. 

URICACIDURIA. 

This name is applied to an over-acid urine containing a 
brick-dust sediment composed largely of uric acid and the 
urates of sodium and potassium, the percentage of uric 
acid always being increased. It may occur physiologically 
when the urine is over-concentrated. It also appears as a 
symptom of gout, rheumatism, acute inflammatory dis- 
orders, nephritic and hepatic diseases, etc. Uricacidsemia 
generally accompanies uricaciduria, and is characterized 
by dull headaches, mental hebetude, nervous irritability, 
heavy, unrefreshing sleep, cardiac irregularity and weak- 
ness, sub-acute muscular pains in various parts of the 
body, painful joints and tender conditions of the fibrous 
tissues, together with inflammation of the mucous mem- 
branes of the nose and throat and urethra. Riggs disease 
of the gums, etc. The term, however, is more frequently 
applied to a urine habitually voided by a seemingly 



312 UROPOIETIC DISEASES. 

healthy individual. The urine in uricaciduria is clear 
when expelled, but soon becomes thick opaque, covered 
with a thin pedicle presenting a play of prismatic colors, 
or after a few hours a large number of the so-called red 
sand crystals appear at the bottom of the recepticle. 

Treatment. — This condition, as well as uricacidsemia, 
has for a number of years been the opprobrium of medical 
practice. In the fall of 1899 Dr. T. F. Allen at the 
Homoeopathic Medical Society of the county of New York, 
presented an elaborate proving of Uranium nitrate, and 
made some remarks upon Hedeomia puleg., and their 
curative action in uricacidsemia. Hedeoma has been care- 
fully proven by Dr. Paul Allen, in whom it produced a 
most perfect picture of this disease. The author has used 
both drugs quite extensively since that time with very 
gratifying results, not only in reducing the specific gravity 
and over-acidity of the urine, and relieving urethral irrita- 
tion, but in erradicating many of the unpleasant general 
accompanying conditions Lycopodium, Sarsaparilla and 
Ocimum are often beneficial. For further symptomatic 
indications see chapters on renal calculus and therapeutics. 

Diet deserves special consideration, the volume of red 
meats daily must be reduced, though fat meats, pork, 
bacon, raw meat juice, creams, milk, eggs and cheese are 
not harmful ; nuts and fruits with edible skins as well as 
lettuce, celery, watercress, chicory, cabbage, cucumbers, 
onions and tomatoes are to be commended. 

Alkaline lithia waters, especially the Bear and London- 
derry or Allouez Magnesia waters, often greatly increase 
the uric acid elimination by their solvent action. On the 
same principle Thialion, a combination of Lithia and a 
saline laxative, a teaspoonful in a glass of water an hour 
before meals often gives immediate relief. 



CHAPTER XXVII. 
RENAL THERAPEUTICS. 

Acidum aceticum. — Urine light-colored, greatly in- 
creased in quantity ; face and limbs have a waxy appear- 
ance. It is especially indicated when the lower part of 
the body and limbs are swollen ; anasarca, with hot, dry 
skin, accompanied by gastric disturbances, sour belching, 
intense thirst, water-brash and diarrhoea. 

Acidum benzoicum. — Urine smells like horse's urine ; 
urine changeable in odor, usually very offensive ; high- 
colored, brownish or black ; urine sometimes thick 
and bloody ; specific gravity increased ; urine hot, 
excoriating, and may contain mucus and pus ; urea 
diminished in quantity ; uric acid normal ; urine cloudy, 
alkaline in reaction, containing phosphates and carbonates 
in large quantities ; frequent desire to urinate, with tenes- 
mus ; patient pale and anaemic ; congestion of the kidney, 
with increased quantity of urine ; dropsy, with the strong, 
highly characteristic odor of the urine which is present 
immediately after it is passed. Frequently useful in 
pyelitis. 

Acidum carbolicum. — Urine scanty, high-colored, green- 
ish or almost black, containing albumen, granular and 
hyaline casts, epithelium and blood corpuscles. When ad- 
ministered to animals in toxic doses it has produced the 
characteristic urine of acute Bright's disease ; increase in 
quantity of urine and frequency in micturition. Acute 
nephritis, with uraemia and coma ; languor of mind and 
body, with headache and vertigo, and sometimes spinal 
pain ; sensation as if a tight band was stretched around 



314 UROPOIETIC DISEASES. 

the forehead and temples ; great fullness of the cerebral 
vessels ; clonic convulsions ; neuralgic pain, especially 
over right eye ; frequent sighing and vomiting. 

Acidum gallicum. — Is useful in three-grain doses three 
or four times daily for the albuminuria which continues 
after the oedema and other acute symptoms of acute ne- 
phritis have disappeared. In this dose it reduces the 
quantity of albumen and increases the flow of urine. 

Acidum hydro cyanicum. — Ursemic convulsions ; convul- 
sions, with drawing backward of the head ; respiration 
irregular and gasping, great distress about the heart, faint- 
ing spells, with coldness and blueness of the surface of the 
body. 

Acidum nitricum. — Anuria; urine reddish, scanty, 
offensive, smelling like horse urine; ammonical, contain- 
ing blood, pus and mucus ; the urine on standing has a 
whitish sediment ; urine is cold when voided ; bloody 
urine ; urging after urinating, with shuddering along the 
spine; albuminuria, with pressing pains in the region of 
the kidneys (five-drop doses of the first decimal dilution 
three times daily increase the secretion of the urine, 
diminish the quantity of albumen voided, and reduce 
the dropsy) ; urine pale, specific gravity low, reaction 
acid; frequently indicated in granular degeneration of 
the kidney, with gastric disturbances and general symp- 
toms of atonic gout, etc., beneficial in amyloid or waxy 
nephritis, with the general symptoms which accompany 
it, especially when of specific origin ; great weakness some- 
times noticed early in the morning is very characteristic ; 
pain of a pressing character in the lumbar region ; 
contractive pain from the kidney towards the bladder ; it 
may be indicated in pyelitis. 

Acidum phosphoricum. — Urine milky, mixed with jelly- 
like and bloody particles ; pale and copious, containing 
excess of phosphates, reaction alkaline; accompanied 



RENAL THERAPEUTICS. 315 

by pain in the back and general nutritive disturbances ; on 
standing the urine becomes dark and turbid, and rapidly 
undergoes decomposition ; albuminous urine ; it is useful 
in amyloid and waxy nephritis, and is well indicated by 
the hectic and other evidences of suppuration elsewhere in 
the body which precede and accompany it ; also useful in 
reducing the quantity of albumen secreted after the subsi- 
dence of an acute attack of nephritis. The mental condi- 
tion of complete indifference is characteristic. 

Acidum picricum. — Urine dark yellow, red, brown, with 
strong odor ; specific gravity increased ; urates abundant ; 
indican abundant ; granular casts ; fatty degeneration of 
the renal epithelium ; it is useful in intermittent hsematuria, 
with degenerated blood corpuscles, the coloring matter 
being liberated and allowed to stain the urine ; also for 
sub-acute and chronic nephritis, with anasarca and dark, 
bloody urine ; soreness over the kidneys, worse on the 
right side ; extreme weakness. 

Aconitum napellus. — Urine scanty, afterwards copious ; 
albuminous, sometimes bloody, containing casts ; sup- 
pressed, dark, red and hot ; acid in reaction. Congestion 
and inflammation of the entire urinary tract ; congestion 
or acute nephritis from cold, with rapid development of 
general anasarca; high fever and restlessness, with pain 
referred to the region of the kidneys ; sensitiveness of the 
kidney region ; weariness and soreness in the lumbar re- 
gion ; it has been very beneficial in acute nephritis from 
cold, after the desquamation of scarlet fever accompanied 
by general dropsy ; the child starts from sleep in agony, 
with cold sweat on the forehead and limbs ; headache, 
pressing from within outwards; throbbing in the forehead 
and temples, aggravated by motion, noise and stooping ; 
oppression in the cardiac region, with palpitation and great 
anxiety. 

Adonis vernalis. — Is a cardiac tonic which increases the 



316 UROPOIETIC DISEASES. 

contractile power of the heart muscles and causes contraction 
of the arterioles and possesses diuretic properties. The 
quantity of urine is rapidly increased under its action and 
cyanosis gradually disappears. Dyspnoea becomes less 
marked and respiration more regular. Botkin employed 
it as follows : 

& Infus. adon. vernal 4.0 ad. 200.0. 

01 menth piper gtt i j . 

Syr. aurant. cort 10. o. 

M. 
Sig. Tablespoonful every two hours. 

It is not cumulative in action though it may nauseate. 
Fifteen to twenty drops may be administered as a dose. 
In five-drop doses three times daily it has controlled 
ursemic convulsions and delirium, reestablished the circu- 
lation action of the kidneys and relieved the immediate 
alarming symptoms. 

Ammonium carbonicum. — Urine red, as if mixed with 
blood ; turbid, high-colored, fetid, alkaline in reaction ; 
micturition frequent; it has been found very useful 
in uraemia, when indicated by somnolency or drowsi- 
ness, with rattling of large bubbles in the lungs ; grasping 
at flocks; bluish or purplish hue of the lips; brownish 
color of the tongue ; stupid, non-active state, etc. 

Ammonium picricum. — Has been of benefit in anasarca 
due to renal derangements. 

Apis mellifica. — Urine milky, high-colored, even black, 
or dark and frothy ; fetid, bloody, containing albumen and 
casts; frequent discharge of small quantities of urine, 
which is burning and scalding, with pain in the small of 
the back ; vesical tenesmus ; general anasarca, most 
marked on the face and head ; the dropsical conditions de- 
velop rapidly; the cedematous parts have a waxy, trans- 
parent hue, with a slightly yellowish cast ; in this dropsical 
condition there is no thirst, the eyelids are markedly 



RENAL THERAPEUTICS. 317 

swollen, and the surface of the body feels sore and bruised. 
It is frequently useful in acute nephritis, following scarlet 
fever or pregnancy, and from other causes, with aching 
pains in the back, and soreness on pressure, or when 
stooping ; suppression of urine, oedema of the lungs, and 
inability to lie down, with mental conditions dulled, etc.; 
twitching of the muscles ; tonic and clonic spasms ; general 
lassitude and trembling ; faintness and prostration ; rapid 
pulse ; worse the latter part of the night, relieved when 
sitting erect. 

Apocynum cannabinum. — Urine copious, watery, light- 
colored and passed almost involuntarily from relaxation of 
the sphincters ; the prover says that he could hardly tell 
when the urine was passing, and scarcely knew when he 
was through, as it seemed to still want to dribble away; 
secondary effect, the urine, from inactivity of the kidneys, 
becomes scanty and high-colored, with dropsy and be- 
wilderment and heaviness of the head, drowsiness, dis- 
turbed, restless sleep, slow pulse, functions sluggish, 
bowels torpid ; oppression in the epigastrium and chest, 
can hardly get breath, even to speak ; a sinking feeling in 
the pit of the stomach and bruised feeling in the abdomen ; 
aching in the small of the back and general anasarca; 
great thirst for water, which nauseates ; fluttering feeling 
in the heart, with distress in the cardiac region ; pulse 
irregular, intermittent, feeble, then slow. It has been used 
to relieve all dropsical conditions and acts kindly, es- 
pecially in dropsy following scarlet fever ; oedema of legs, 
feet and ankles. It is given in substantial doses of one to 
five drops of the tincture, or as " Hunt's decoction." 

Argentum nitricum. — Urine dark, containing blood and 
renal epithelium ; urine scanty, concentrated, percentage 
of inorganic salts increased, with disappearance of uric 
acid ; sudden urging to urinate, with dull aching in the 
small of the back and over the bladder ; face rather dark 



318 UROPOIETIC DISEASES. 

in color and has a dried-np appearance ; has been useful 
in congestion of the kidneys and in nephralgia ; urine 
burns while passing and the urethra feels sore ; drowsi- 
ness, stupor ; as if turning in a circle, accompanied by 
headache ; head feels painfully full, relieved by being tied 
up ; congestion of the head with throbbing carotids ; 
gloomy ; time passes slowly ; worries because others con- 
sume so much time when their acts are in reality accom- 
plished rapidly ; impulsive, always in a hurry ; nervous 
and easily excited, irritable and anxious. 

Arnica montana. — Urine bloody after injuries to the 
kidneys ; urine brown, high-colored or black, of high 
specific gravity, becoming opalescent on boiling and clear- 
ing on the addition of Nitric acid ; urine loaded with 
phosphates ; bloody urine with red sediment, with cutting 
pains in the region of the kidney ; hsematuria ; retention 
of urine from over-exertion. 

Arsenicum album. — Urine burning, high-colored, dark, 
scanty or suppressed, containing albumen, with an abun- 
dance of waxy and fatty casts, fat globules, blood and 
renal epithelium ; specific gravity diminished ; urine mixed 
with pus, turbid, greenish, foul-smelling, slimy ; dark 
brown sediment ; suppression of urine, with great anxiety, 
restlessness and sinking of the vital forces ; uraemia 
(animals poisoned with Arsenic die comatose and post- 
mortem examination shows the kidneys to be congested 
and enlarged, the epithelial cells charged with fatty 
granules, and hypertrophy of the left ventricle was fre- 
quently found) ; urine voided with great difficulty ; oedema 
more or less general, beginning with pufrmess of the eyes 
and extremities and terminating in general anasarca ; 
tingling in the fingers, especially of the left hand ; 
dyspnoea, due to cardiac asthma ; the heart may beat too 
strongly, being visible to the friends, or audible to the 
patients themselves ; aggravated at night and by lying on 



RENAL THERAPEUTICS. 319 

the back ; cardiac palpitation and irregular rhythm of the 
pulse ; the heart may be weak and accelerated ; the 
dyspnoea may be due to oedema of the lungs, and is 
noticed more when attempting to lie down, in the even- 
ing, and especially recurs at 12 p. m., and is relieved by 
expectoration ; the dropsical parts have a pale waxen 
look, and blisters appear on the limbs and burst, allowing 
serum to ooze from them ; the skin feels cool, while the 
patient complains of thirst for small quantities of water 
and requires it frequently, but even this may irritate the 
stomach and cause vomiting. This drug acts well in the 
nephritis of scarlet fever and the chronic nephritis of 
malarial origin, with hypertrophy of the left ventricle of 
the heart and especially in the large fatty kidney ; great 
anxiety is always present, with a feeling that it is useless to 
take medicine as they are sure they are about to die ; 
great anguish ; rapid sinking of strength and great 
emaciation ; relieved by warmth ; wants to be wrapped up 
warm. 

Aurum muriaticum. — Urine clear, copious, albuminous, 
containing a few casts, urine increased in quantity at first 
from hypersemia of the kidneys, finally becoming turbid, 
resembling buttermilk, scanty and albuminous, with fre- 
quent micturition ; worse at night ; pressing pains or feel- 
ing of heat around the waist extending to the bladder or 
down the sides, accompanied by depondency ; suicidal ten- 
dency. It has been used successfully in the dropsy of 
pregnane}^ and chronic Bright's from syphilis ; it rarely 
does any good unless the condition is secondary to cardiac 
or hepatic disease, with nervous symptoms hypochondriasis, 
over-sensitiveness to pain, irritability, and vertigo. In 
interstitial nephritis it diminishes the quantity of albumen. 

Belladonna. — Urine scanty, deep red, turbid like yeast, 
albuminous, with reddish or thick white sediment, mictur- 
ition difficult, voided by drops ; congestion or acute inflain- 



320 UROPOIETIC DISEASES. 

mation of the kidneys, with, flushed face and feverish con- 
dition, possibly delirium, with tendency to strike and bite. 
The least jar of the patient increases the pain, etc. It 
relieves the congestion of the Malpighian capillaries, but 
does not have any effect upon the secreting epithelium of 
the convoluted tubes ; large doses aggravate, while smaller 
doses rapidly relieve the renal hypersemia. 

Berberis vulgaris. — Urine yellow, red with a reddish and 
bran-like sediment, frothy ; blood-red urine ; greenish urine, 
or pale yellow with slight, transparent, gelatinous sediment 
which does not deposit ; or a turbid, flocculent, clay-col- 
ored, copious mucus sediment, mixed with white or 
whitish-gray, and later a reddish, mealy sediment ; stick- 
ing, digging, tearing pains in the region of the kid- 
neys, worse from pressure ; tearing pains extending from 
the back down the ureters into the pelvis ; in . fact, in 
all directions to the pelvis, hips and loins, labia and testi- 
cles, etc. ; tensive, pressing pains across the small of the 
back ; back feels stiff and numb ; a bubbling feeling as if 
water was coming up through the skin. Violent stitching, 
tearing, burning pain in the region of the kidneys, ex- 
tending forward along the course of the ureters into the 
bladder, to the posterior part of the pelvis and thighs ; 
worse from stooping, lying or sitting, relieved by stand- 
ing ; stitches from the kidney to the bladder, with frequent 
desire to urinate ; drawing, tensive, tearing pains in the 
lumbar region ; violent stitches in the bladder with fre- 
quent micturition ; cutting, constrictive pain in bladder, 
whether full or empty ; desire to urinate, with burning in 
urethra ; burning in the urethra after micturition ; motion 
aggravates the urinary troubles ; pain in the loins and 
hips generally accompanying the symptoms; vesical irri- 
tability ; burning, cutting and sticking pain in the 
urethra ; frequent micturition, with burning before and 
during the act, especially in the female. This remedy has 



RENAL THERAPEUTICS. 321 

been of marked benefit in renal colic, gravel, and pyelitis, 
with great general prostration ; the face often gives evi- 
dence of deep distress or disease. 

Caffeine. — Is a diuretic and heart tonic ; acts well in 
chronic croupous nephritis, with dilated heart and mitral 
or aortic disease ; for general anasarca and ascites, three- 
grain doses, three times a day ; it acts more promptly than 
Digitalis, and is not cumulative in action ; five grains has 
been known to cause cardiac distress, though eight to 
thirty grains are frequently given daily. 

Calcarea carbonica. — Offensive, dark urine, containing 
thick mucus and depositing a white sediment like flour ; 
involuntary discharge of urine when walking ; frequent 
micturition at night ; nocturnal enuresis, urine clear and 
sour-smelling. Prof. L,illienthal considered this remedy in 
the thirtieth potency the most frequently indicated and 
the most useful remedy in renal colic. It is especially in- 
dicated in stout, flabby and light-complexioned patients 
and for ailments arising from living in damp houses or 
places. 

Camphor. — Urine scanty, red or dark yellow, sometimes 
green ; strangury ; renal congestion has sometimes been 
relieved by this remedy ; coldness of the body, yet the 
patient throws off the clothing, and will not remain 
covered. 

Cannabis Indica. — Urine copious, clear and light-colored 
or colorless ; at times scanty, dark and red, with burning 
and biting on micturition ; it has given good results in 
uraemia with severe headache and sensation as if the vertex 
was opening and closing ; forgetful ; forget what they 
intended to say ; conflicting thoughts, associated with de- 
lusion of time and space ; they tell you they have had 
nothing to eat in months, when the empty dishes are before 
them ; objects a few feet distant seem a long distance 
off; all sensations and emotions (be thev pleasant or pain- 
21 



322 UROPOIETIC DISEASES. 

ful) are exaggerated. These mental indications frequently 
lead us to the use of this remedy in chronic nephritis, with 
very gratifying results. 

Cannabis sativa. — Urine scanty, red and turbid, with 
drawing pains in the region of the kidneys extending to 
inguinal region, with anxious sensation at the epigastrium ; 
useful in Bright's disease accompanying, or the sequella of 
urethritis or cystitis. 

Cantharides. — The specific gravity of the urine is always 
high, the reaction acid, and it contains large quantities of 
urates ; urine red, dark, scalding and scanty ; contains 
blood and pus corpuscles, epithelium and casts from the 
tubuli uriniferi; hsematuria, urine red, as if mixed with 
blood, turbid, albuminous; micturition frequent and ex- 
ceedingly painful, especially after the act. It acts on the 
secreting parts or tubes of the kidney tissue, and is useful 
in suppression of the urine in nephritis following scarlet 
fever, and other acute forms from cold, exposure, etc.; 
ursemic symptoms, stupor and mental torpor, with high 
fever, hard, frequent pulse, pain in lumbar region, and 
drawing, tearing pains in the region of the kidney, which 
is sensitive to the slightest touch, with tenesmus of the 
bladder; pains in the kidneys, loins and abdomen, with 
constant desire to urinate ; burning, stinging and tearing 
in the region of the kidneys ; violent pressing pain 
in the lumbar region, extending to the bladder ; the cys- 
titis calling for Cantharides is of a high inflammatory grade, 
with hematuria ; it may be accompanied by a chill, fever, 
etc.; in the gravel of children the pains extend down the 
penis, and there is a constant inclination to pull at the 
organ ; thirst, but drinking always increases the pains 
in the bladder. The drug is useful also as a diuretic in 
chronic Bright's disease, relieving the cephalalgia, mental 
symptoms, coma, etc. ; it may be useful for the convulsions 
and frequently prevents their appearance. 



RENAL THERAPEUTICS. 323 

Carbo vegetabilis. — Urine has a strong odor, is dark- 
colored, as if mixed with blood, and deposits a sediment. 

Causticum. — Urine light-colored, with flocculent sedi- 
ment; lithiates ; urine loaded with urates from disease or 
exhaustion, without other marked symptoms ; azoturia, 
with depression of spirits, debility, sour perspiration and 
excessive tissue waste. 

Cerefolius. — In acute Bright's disease Fanning says it is 
almost a specific. It should be given in the first dilution 
or tincture. 

Chelidonium majus. — Urine dark yellow, turbid when 
passed ; dark red or brown like beer, tinged with bile, and 
containing an excess of phosphates and uric acid, tube 
casts and epithelial cells, with diminution of the chlorides ; 
oedema of the extremities. Croupous nephritis has been 
cured with this remedy ; it is especially useful in the ne- 
phritis accompanying pneumonia in children. Pain in 
right kidney and liver ; pains from the kidneys towards 
bladder, followed by evacuation of turbid urine; drawing, 
tearing pains in the back, as if broken, aggravated by 
motion. 

Chininum sulphuricum. — Gravel ; urine is scanty, acid, 
turbid, of strong odor, and flows slowly ; a sediment of 
yellowish-red crystals, or clear, containing four-sided 
prisms, the pointed ends being enveloped in mucus ; urine 
turbid, alkaline, chocolate-colored, with increase of phos- 
phates; sediment yellowish-white, mealy, like brick-dust, 
or in slimy flakes, with large numbers of transparent, 
colorless and orange-like crystals ; star-like, rhomboidal 
and flat crystals, mostly phosphates ; cramping and neural- 
gic pains in the region of the kidneys. 

Chloralum hydratum. — Has been used extensively in 
uraemic convulsions in ten to thirty-grain doses in rectal 
suppositories or injections. 

Cina. — Urine turbid and increased in quantity, urea 



324 UROPOIETIC DISEASES. 

augmented ; urine has an orange or bloody tint ; hsema- 
turia in children ; bruised feeling in small of the back, not 
increased by motion ; a feeling of constriction around the 
loins. 

Coccus cacti. — Renal colic ; chronic cystitis ; drawing, 
lancinating pain in lumbar region, extending along the 
course of the ureters ; cutting pain and heaviness in the 
bladder, with constant urging to urinate, relieved by 
micturition; frequent ineffectual attempts to urinate at 
night, has to wait a long time before he can succeed ; re- 
tention of urine until it causes intense pain, when a small 
amount is slowly passed, with much suffering ; pain and 
soreness in the region of the bladder ; hsematuria. 

Colchicum. — Urine dark, turbid or bloody, black as ink > 
albuminous, scanty or dark brown, with frequent urging 
to urinate ; dropsy in gouty patients, with nervous weak- 
ness and hypersensitiveness ; oversensitiveness to touch ; 
senses too acute, affected by strong odors ; gastric symp- 
toms prominent ; mental labor fatigues ; inability to fix 
thoughts or think connectedly ; headache ; sleepiness dur- 
ing the day, wakeful at night; awakes with frightful 
dreams ; the scalp feels tense ; tongue coated, nausea, great 
muscular weakness, copious salivation and increased 
urinary secretion ; nephritis, with severe drawing, stitch- 
ing, tensive pain in the region of the kidneys, aggravated by 
stretching out the legs, by pressure over the kidneys, relieved 
by lying on the back and drawing up the legs ; pain in 
the back and sacrum ; constant chilliness, with cold ex- 
tremities ; coldness in the stomach ; dropsy, with sup- 
pression of urine ; Bright's disease, with hydrothorax. 
Ruddock especially recommends this remedy in cirrhosis 
of the kidney, due to lead poisoning in the gouty, with 
developing amaurosis. 

Convallariamajalis. — Urine scanty and albuminous ; fre- 
quent micturition, the urine is burning and hot ; lame 



RENAL THERAPEUTICS. 325 

feeling in the back, aggravated by lying down ; constant 
gasping for breath ; severe palpitation of the heart ; violent 
stitch-like pain on turning to that side, causing him to cry 
out ; it has been useful in the dropsies of chronic croupous 
and interstitial nephritis, and in the nephritis following 
scarlet fever ; cardiac hypertrophy and valvular lesions ; 
cardiac irregularity. 

Copaiva. — Urine bloody and albuminous, with strangury; 
urine copious, burning and scalding when voided ; large 
doses cause renal congestion, and consequently scanty 
urine. It has cured desquamative nephritis with ascites 
and general anasarca, as well as nephritis following scarlet 
fever. 

Cuprum aceticum. — Urine dark red ; complete suppres- 
sion ; albuminuria ; ursemic vomiting, stupor, convulsions, 
with blueness of the face and lips, eyeballs rotated inwards, 
frothing at the mouth, with violent convulsions ; extensor 
muscles most prominently affected ; convulsions, followed 
by deep sleep ; dyspnoea, delirium, awakening with fright ; 
uraemia, resulting from fatty degeneration of the kidneys. 
Convulsions begin in the fingers and toes and spread over 
the body ; great restlessness between the attacks ; decided 
metallic taste in the mouth. 

Digitalis purpurea. — Urine dark red, blackish, turbid, 
scanty, albuminous and of high specific gravity ; it may be 
suppressed or copious with constant urging to urinate and 
inability to retain it (the urine, however, is more easily re- 
tained in the recumbent position); specific gravity di- 
minished ; it is useful when the dropsy is due to or asso- 
ciated with cardiac weakness ; it is indicated in anasarca, 
with bluish cast of the cedematous portion of the body ; a 
very frequent symptom is infiltration of the scrotum and 
penis; suffocative spells with sensation of contraction of 
the chest, as if it were grown together ; passive hyperaemia 
of the kidneys ; pulse feeble and slow, greatly accelerated 



326 UROPOIETIC DISEASES. 

on standing (hydropericardium) ; dropsy, with scanty, 
turbid, albuminous urine ; sinking and faint feeling at the 
pit of the stomach ; in large doses it is a diuretic, but the 
increased secretion of urine favors the retention of urea ; in 
acute nephritis it is used as a diuretic, but it acts best in 
passive renal congestion due to enfeebled muscular power 
of the left ventricle and deficient action of the tricuspid 
valve, with scanty urine, oedema of the lungs and dropsy. 
Digitalis is not a renal irritant ; it is frequently prescribed 
as follows : 

fy. Tine, digitalis gss. 

Acetum scillae § jss. 

Spiritus etheris nitric § ji. 

M. 
Sig. Teaspoonf ul every three or four hours. 

Or Digitaline one-fourth to one-half a milligramme in 
divided doses in twenty-four hours, or four drops of the 
tincture from the fresh plant every three or four hours ; 
sometimes teaspoonful to tablespoonful doses of the in- 
fusion made from the English leaves, repeated every four 
hours, quickly reduce dropsical accumulations, by increas- 
ing the systolic contraction of the heart. 

Dulcamara. — Urine scanty, bloody, albuminous ; ne- 
phritis resulting from cold and wet ; acute croupous ne- 
phritis, with drawing pain in the small of the back, and 
chronic nephritis from the same cause with copious dis- 
charge of urine which is turbid and offensive ; great lassi- 
tude ; a feeling of fatigue compelling one to sit or lie 
down. 

Euonymin. — Urine albuminous, with depression of 
spirits ; headache, pain in the head and back, convulsions, 
thickly-coated tongue, dyspepsia, nausea ; especially use- 
ful when associated with derangements of the liver and 
general anaemia. 

Eupatorium perfoliatum. — Nephritis of malarial origin, 



RENAL THERAPEUTICS. 327 

especially when associated with the characteristic chill, 
fever, and great pain in the bones. 

Equisetum hyemale. — Urine scanty, high-colored, al- 
buminous, bloody. 

Ferrum muriaticum. — Urine copious, reddish ; specific 
gravity varying from 1005 to 1025 ; loaded with blood 
corpuscles ; copious, with whitish sediment ; copious, with 
prostration and nervousness ; constant urging to urinate, 
with pain in the chest, liver, and region of the kidneys ; 
pain in lumbar region, relieved by walking, worse after 
sitting ; chronic Bright's disease ; fatty degeneration of 
the kidneys ; albuminuria. It is efficacious in proportion 
as the hepatic, digestive and assimilative functions are 
normal, and the elimination of albumen is independent 
of recent congestion or inflammation ; it is beneficial in 
the enfeebled action of the heart, especially in chronic or 
sub-acute interstitial nephritis ; it reduces the amount 
of albumen, epithelium, etc. It is indicated in those who 
are much debilitated, especially when the face is pale and 
flushes easily. 

Ferrum phosphoricum. — Urine pale and copious. It is 
useful in chronic Bright's disease, diminishing the secre- 
tion of albumen. 

Formica rufa. — Urine albuminous and bloody, with 
much urging to urinate. 

Glonoinum. — Urine copious, albuminous and high- 
colored; polyuria, with very low specific gravity, great 
arterial tension, and violent action of the heart ; it has 
acted kindly in puerperal convulsions occunng during 
labor; face bright red and puffy, pulse full and hard, 
frothing at the mouth, patient unconscious, hands clenched, 
with thumbs in the palms ; cerebral hyperaemia, pain in 
head, aggravated by shaking he head or moving the body, 
relieved by external pressure ; sensation or tension, throb- 
bing, etc., in the heart. It acts kindly in anaemic dyspnoea. 



328 UROPOIETIC DISEASES. 

Graphites. — Urine ill-smelling, dense, deposits a thick, 
white sediment ; urine covered with an iridescent film, or 
has a sour odor ; pain in the sacrum and coccyx on urinat- 
ing. 

Hamamelis virginica. — Urine bloody ; back feels as 
though it would break. 

Hedeorna pulegioides. — The percentage of uric acid in 
the urine is primarily increased, later it is decreased, 
accompanied with polyuria. Frequent desire to urinate, 
accompanied with dragging pains, referred to the 
neck of the bladder. Uric acid; scalding the urethra. 
Dragging pains in the left kidney, extending into the 
bladder. Left hip sore. Flatulency and mental depres- 
sion. Clinically it has been beneficial in renal calculi ; 
uricaciduria and uricacidaemia. 

Helleborus niger. — Urine dark, scanty and smoky ; con- 
taining blood, depositing on standing a sediment looking 
like coffee grounds ; congestion of the kidneys, with fre- 
quent urging to urinate, with anasarca and ascites ; dropsy 
following scarlet fever ; suppression of the urine ; torpor 
predominates ; blunting of the general sensibilities ; eyes 
do not react to light, or while the patient sees imperfectly 
he does not regard the objects seen, hardly remembers 
what he sees or hears ; takes no pleasure in anything ; cor- 
rugation of the muscles of the forehead ; slow pulse with 
rapidly developing dropsies ; giddiness, stupor or excite- 
ment and restlessness ; pupils dilated and squinting ; pain 
in the head so violent that there is constant change of 
position ; headache referred to the occipital region ; dull 
pain, worse on stooping, extending from the neck to the 
vertex ; stiffness and contractive pains in loins as if beaten ; 
face swollen and puffy ; nausea and vomiting ; absence of 
thirst ; convulsions with cold extremities. This remedy 
acts in acute nephritis with sudden dropsies, with urine 
scanty and albuminous, best in five-drop doses of the tine- 



RENAL THERAPEUTICS. 329 

ture; it is frequently called for in nephritis following 
scarlet fever. The secondary effect of Helleborus is an 
increased secretion of urine which is voided without 
urging. 

Helonias dioica. — Urine copious, finally becoming scanty, 
light-colored, urea increased, specific gravity lowered ; pain 
over the kidney region, with suppression of the menses, 
congestion of the kidneys, and albuminuria; phosphates 
increased ; urine turbid and scanty, frequent micturition, 
with weakness and great restlessness ; stupid, depression of 
spirits, loss of appetite, easily fatigued, debility, emaciation, 
tired feeling; nephritis of pregnancy; pain, weight and a 
sensation of burning in the region of the kidneys. All 
symptoms are relieved by motion. 

Hepar sulphur calcareum. — Urine dark-red, hot, becomes 
thick, turbid, and deposits a white sediment on standing. 
It has been especially useful in post-scarlatinal nephritis, 
where there is a large quantity of mucus and epithelia 
deposited in the urine. 

Hydrangea arborescens is a valuable and important 
remedy for gravel and renal colic ; in a large number of cases 
where it has been given for some months without special 
diet there was no return of the trouble. It causes the 
excess of urates and white amorphous salts to disappear 
from the urine. It should be given in seven-drop doses of 
the fluid extract, in a little water, four times a daily. 

Ignatia amara. — Urine lemon-colored, with white sedi- 
ment; frequent discharge of watery urine; pressure to 
urinate after drinking coffee. 

Ipecacuanha. — Hsematuria ; hemorrhage from the kid- 
neys, attended with nausea and vomiting, with cutting 
pains in the renal region, especially after the abuse of 
quinine. 

Kali bichromicum. — Urine scanty, reddish, high-colored 
and hot ; suppression of the urine, with pain in the region 



330 UROPOIETIC DISEASES. 

of the kidneys. In animals poisoned with this drug the 
kidneys are found greatly congested, and the tubular 
portion softened and undistinguishable from the rest of the 
kidney tissue; the urine may be purulent, or suppressed. 

Kali carbonicum. — Urine dark and turbid, loaded with 
urates ; weak, lame feeling in the small of the back, with 
great exhaustion of the muscular system ; aggravation of 
all symptoms from 3 to 4 A. M., and from cold. 

Kali chloricum. — Urine bloody, scanty, albuminous ; 
acute nephritis. 

Kali hydroiodicum. — Urine dark and scanty, with a 
dirty yellowish sediment, or copious and clear; urea di- 
minished, thirst, with heat in the head ; useful in sub-acute 
and chronic nephritis of specific origin with darting pains 
in the region of the kidneys ; feeling as if the small of the 
back was being squeezed in a vise ; burning pain in the 
lumbar region, with difficulty in walking. 

Kalmia latifolia. — Urine yellow and copious, or dimin 
ished in quantity, feeling hot when voided ; micturition 
frequent ; pain in renal region, worse at night ; pain in 
the cardiac region and excessive palpitation. Is especially 
useful in the sub-acute nephritis of pregnancy. 

Lachesis. — Urine dark, almost black, albuminous ; the 
respiratory symptoms and all other conditions are worse 
after sleep ; the blue condition of the cedematous surfaces 
are characteristic; dyspnoea on awakening, inability to lie 
down ; drawing pains in the back extending to the hips or 
up the back. This remedy may be called for in the 
nephritis of scarlet fever and diphtheria. 

Lithium carbonicum. — Urine red, scanty, turbid, with 
reddish-brown sediment ; albuminuria, with frequent uri- 
nation, accompanied by great debility and especially an 
over-acid condition of the stomach. 

Lycopodium clavatum. — Urine turbid, with red sandy 
deposits ; lithsetnia, colic with pain on the right side, urine 



RENAL THERAPEUTICS. 331 

dark and burning ; urine of strong odor, suppressed, some- 
time copious ; calculus with blood) 7 urine ; urine profuse, 
dark, bloody, with much red sandy sediment ; greasy coat- 
ing on the surface of the urine ; red sand on child's diaper ; 
before micturition the child screams with pain ; urine 
turbid, milky, with a thick purulent sediment and offensive 
odor; pressing pain in perineum during and after mictu- 
rition ; urging to urinate, must wait some time before he 
can void it ; frequent desire to urinate with scanty flow ; 
terrific pain in the back before urination, relieved as soon 
as the flow begins ; smarting and burning when urinating ; 
drawing, cutting pain through to the abdomen ; pain in 
kidney and bladder with frequent urination ; renal colic 
from the passage of small calculi, the pain is burning and 
cutting in character; useful in chronic Bright's disease 
with anasarca and the characteristic digestive disturbances ; 
dropsies of the lower half of the body ; the upper part, 
arms and chest emaciated ; abdomen and leg swollen, 
cedematous, covered with ulcers from which serum oozes ; 
all symptoms worse from 4 to 8 P. M. 

Mercurius corrosivus. — Urine copious, afterwards thick, 
scanty, bloody, and acid in reaction ; it has caused com- 
plete suppression; urine albuminous, containing granular 
and fatty casts with epithelia from the tubuli uriniferi ; the 
general firmness of the tissue of the body disappears ; skin 
brown, earthy and pale, eyelids and ankles cedematous, 
with loss of appetite, quick and frequent pulse, great weak- 
ness and prostration, disposition to perspire on the slightest 
exertion, lassitude and soreness, great restlessness in the 
limbs, must change position constantly ; sleepiness during 
the day, but not relieved by long sleep ; sleep at night 
disturbed, awaking with dreams which terrify ; dullness in 
the forehead ; aching and weariness in the back of head 
and neck ; sensation as if a band was tied around the head ; 
qualmishness, weakness and tenderness in the epigastric 



332 UROPOIETIC DISEASES. 

region ; nephritis complicating pregnancy ; suppurative 
nephritis ; inflammation of the kidneys, with scanty albumi- 
nous urine, frequent urination and pain in the back ; in 
acute nephritis, the albumen, blood and oedema rapidly 
disappear under this remedy. 

Mercurius dulcis. — Is often required in interstitial ne- 
phritis. 

Nux vomica. — Urine pale, containing thick, white 
mucus or purulent matter ; dark urine, depositing a red 
brick-dust sediment ; bloody urine ; nephritis, accompanied 
by digestive disturbances ; vomiting, of renal origin, 
nausea after eating ; thirst, polyuria ; patient irritable, 
sullen, with desire to be alone, and to recline and keep 
quiet, etc. 

Ocimum canum. — Urine red, with brick-dust sediment 
and blood ; saffron-colored urine ; turbid urine, depositing 
a white albuminous sediment ; burning during micturi- 
tion ; pain in ureters, and deposit in urine of a large 
quantity of red sand ; renal colic ; gravel ; cramping pain 
in the kidneys, especially the right ; renal colic, with 
micturition every fifteen minutes ; the pain causes the 
patient to wring his hands, moan and cry. 

Opium. — Urine red, scanty and cloudy, or lemon-colored, 
with a reddish sediment ; indicated in ursemic coma from 
contracted kidneys ; morphia, in one-fourth to one grain 
doses hyperdermically, has been successfully used in 
ursemic convulsion. 

Oxydendron arboreum. — This remedy in five-drop doses 
of the tincture has its reported cures of general dropsy. 

Petroleum. — Urine dark yellow, bloody and turbid, con- 
taining brown clouds after standing ; odor offensive, sour, 
ammoniacal ; urine suppressed during the day, copious at 
night ; urine albuminous, containing granular and hyaline 
casts ; urine has a reddish sediment, and is covered with a 
glistening film ; useful in chronic nephritis with gastric 



RENAL THERAPEUTICS. 333 

symptoms and dropsy, also in renal haemorrhage, with 
pain in the renal region ; chilliness, frequent micturition, 
and oedema of the lower extremities. 

Phosphorus. — Urine thick, turbid and scanty, containing 
blood corpuscles and albumen ; urine brown, with red 
sandy deposit ; urine bloody ; it may be pale, watery, or 
whitish like curdled milk, containing fatty and waxy 
casts, pus and blood corpuscles ; specific gravity dimin- 
ished ; acute pain in the region of the kidneys and liver, 
with jaundice ; urine covered with an iridescent fatty 
matter ; preeminent in fatty and amyloid degeneration of 
the kidneys when associated with similar pathological con- 
ditions of the liver and right heart ; venous stasis ; 
oedema of the lungs ; weakness of memory ; difficulty in 
concentrating the mind ; vertigo ; confusion in head ; 
weak, empty feeling in the whole abdomen ; especially in- 
dicated in tall, slender individuals. 

Phytolacca decandra. — Urine dark red, mahogany 
colored, with painful micturition; pain and soreness in right 
renal region ; has been beneficial in chronic nephritis. 

Pichi. — Urine bloody, epithelial, granular or waxy casts; 
acute nephritis. 

Pilocarpin muriaticum. — One-fourth to one-third grain 
doses of the hydro-chlorate hypodermically three times a 
day has been followed by profuse sweating and lowering 
of the temperature. In a case reported of convulsions 
in puerperal nephritis with complete anuria and face 
and body highly ©edematous, the convulsions ceased with 
the re-establishment of the urinary secretion, and recovery 
followed. 

Plumbum- metallicum. — Urine scanty and dark ; albu- 
minous, not accompanied by general oedema ; urine 
brownish-red, turbid, sediment containing blood corpuscles, 
casts and albumen in abundance ; has been useful in acute 
nephritis with mental depression and bloody urine, but is 



334 UROPOIETIC DISEASES. 

especially indicated in chronic granular gouty or cirrhotic 
kidneys with amaurosis, depression of spirits, cachexia, 
numbness of the lower extremities and dropsy. It has 
been found to diminish the quantity of albumen ; uric acid 
is diminished ; cerebral symptoms ; clonic spasms of the 
face and limbs, slight dropsy, little albumen, with a marked 
tendency to uraemic convulsions ; small granular con- 
tracted kidney and albuminuria is found in a large per- 
centage of patients with lead poisoning ; in chronic lead 
poisoning it causes interstitial nephritis, atrophy of the 
kidney, adhesion of the capsule, and the formation of 
small cysts in the substance of the kidney ; the tubuli 
uriniferi are first affected, causing proliferation of the 
epithelia and formation of casts ; it involves both the 
cortical and medullary portions of the kidney, but some 
portions of the kidney are more affected than others, and 
many symptoms similar to gout are developed while the 
chronic poisoning is going on. 

Pulsatilla nigricans.— Urine bloody, reddish mucus, jelly- 
like, slimy deposit which sticks to the chamber ; brick-dust 
sediment ; suppression of the urine with the general symp- 
toms of this remedy ; spasmodic pain at the neck of the 
bladder extending to the pelvis and thighs ; frequent and 
almost ineffectual urging to urinate ; involuntary urination 
at night in bed ; constant pressure in the bladder, with 
frequent desire to urinate ; the urine is discharged while 
walking or standing. 

Rhus toxicodendron. — Urine dark, turbid and scanty ; 
has been useful in acute nephritis with cutting pains in the 
back, general oedema resulting from exposure to wet, great 
oedema of the legs, with ulcers exuding serum. 

Sabina. — Urine red and scanty, bloody, albuminous ; 
strangury ; dragging pains in the back extending to the 
pelvic region and thighs in rheumatic and arthritic sub- 
jects. 



RENAL THERAPEUTICS. 335 

Sambucus. — In the Georgia Journal of Medicine and 
Stirgery, April, 1899, Dr. John W. Daniel states that, his 
attention having been called to the virtues of Sambucus or 
elder, some years ago, he has since used it in several cases 
of nephritis, following scarlatina, with the result of recov- 
ery in every case. He employs only the inner bark of the 
plant, because it can be obtained fresh at any season. Of 
this he makes an infusion, allowing it to simmer for six 
hours or more. Patients do not object to the taste and 
they take from a pint for children to a quart or more for 
youths and adults. He has used it only in cases compli- 
cating or following scarlatina, both in their beginning and 
after the complaint has lasted a few weeks or months. He 
relates two successful cases from his own practice within 
the last year, and adds that he has seen the infusion ad- 
ministered in four other cases of scarlatinal nephritis with 
anasarca of two to three months' standing, all cases being 
attended by the best physicians in the community, the reg- 
ular treatment being used and each case having been 
pronounced incurable, the result being recovery, and two 
cases being now free from albumen after ten years. 

Sandal wood. — Urine albuminous, associated with great 
pain in the lumbar region ; acute nephritis. 

Sarsaparilla. — Urine copious, clear, scanty and slimy ; 
clay-colored and scanty ; sand in the urine or on the 
diaper ; child screams before and during micturition ; the 
urine contains pus, blood and mucus ; fiery red, turbid 
urine containing long flakes ; urine excoriating ; pain in 
the lumbar region going forward ; abdomen distended ; 
severe tenesmus ; painful constriction of the bladder ; 
micturition frequent and ineffectual, ending by passing 
blood ; chills run from the bladder to the back ; gravel 
passes after urinating ; has to get up in the night fre- 
quently to urinate ; retention of urine. 



336 UROPOIETIC DISEASES. 

Secale cornutum. — Urine has a cheesy sediment ; has 
been used in post-scarlatinal nephritis. 

Senecio aurens. — Urine scanty and bloody ; inflammation 
of the kidneys with renal dropsy and pain in the kidney 
region resulting from or following the passage of a urinary 
calculus ; sometimes useful in oedema of the lungs accom- 
panying croupous nephritis ; dyspnoea on ascending the 
stairs. 

Senna. — Excess of urea, chloride of sodium and phos- 
phates in the urine. 

Sepia. — Urine thick, slimy, offensive, depositing a 
yellowish, pasty sediment; urine turbid, clay-colored; urine 
turbid and dark when passed, as if mixed with mucus ; on 
standing it deposits a white or reddish sediment and be- 
comes offensive ; deposit of brick-dust sediment, uric acid, 
bile pigment, blood, etc.; fetid urine, with reddish, clay- 
colored sediment adhering to the chamber ; the urine is so 
offensive that it must be removed at once ; the discharge 
of mucus in the urine does not take place every time the 
urine is passed, but occurs periodically ; urine dark, turbid, 
and mixed with pus ; thick, slimy, turbid and offensive, 
depositing a pasty sediment ; the lower part of the abdomen 
feels distended, with tension and soreness ; frequent, pain- 
ful, and ineffectual urging to urinate, until long effort and 
waiting have about tired out the sufferer ; desire to urinate, 
with bearing down in the pelvis ; burning and cutting 
when urinating ; chill and heat in the head during and 
after micturition; pulsation in the small of the back; 
sprained pain over the hips ; pain in the lumbar region ; 
deep-seated pressive pain and tension in the lumbar region ; 
gravel; pyelitis. 

Stigmata maidis. — Retention of urine ; renal colic ; 
gravel ; acute and chronic cystitis ; vesical tenesmus and 
irritation ; pyelitis. 



RENAL THERAPEUTICS. 337 

Stramonium. — Suppression of urine, with the character- 
istic mental symptoms. 

Sulphur. — Urine clear, high-colored or turbid, of pene- 
trating odor, with thick deposit, which sticks to the cham- 
ber ; retention of urine ; urinates frequently, with a feeling 
of obstruction at the neck of the badder and a sense of 
pressure and distension ; bruised sensation in small of back 
after micturition ; the pains continue in the urethra until 
the urging to urinate returns ; increased secretion of 
urine ; frequent urination at night ; the desire comes sud- 
denly, is imperative, and if not gratified at once micturition 
becomes involuntary ; pyelitis ; constant urging to urinate 
day and night, in a thin stream or drop by drop. 

Terebinthina. — Urine bloody, scanty, smoky, with a coffee- 
ground deposit, the sediment consisting of disintegrated 
blood corpuscles and casts ; dull, burning pains in kidneys, 
especially from the right kidney to the hip ; burning dur- 
ing micturition ; urine dark, cloudy, smoky, containing 
albumen ; pressure from the bladder to the kidneys, 
relieved when walking ; acute or chronic nephritis from 
cold or malaria. It causes active congestion of the capil- 
laries of the Malpighian tufts and glomeruli and destroys 
the epithelium of the tubuli uriniferi, with exudation of 
blood and albumen ; renal hyperaemia and congestion, 
hsematuria ; suppression of urine ; uraemia is rare. It 
is often indicated in dropsy after scarlet fever, but more 
frequently when resulting from colds and when congestion 
is more marked than the evidence of change in the 
epithelium of the tubules would seem to warrant ; its first 
effect is to make the urine more copious ; dyspnoea ; 
patients must be propped up in bed ; tongue dry and 
glossy ; stupor and general weakness. 

Thlaspi bursa pastoris. — This remedy has a marked 
diuretic action, producing a frequent desire to urinate ; 
urine heavy, scanty, with a brick-dust deposit, containing 
22 



338 UROPOIETIC DISEASES. 

crystals of uric acid and phosphatic material, accompanied 
with pains in the renal and ureteral regions. It has given 
excellent results in hsematuria ; urine smells strong. It 
has also its reputed cures of dropsy. 

Ulex diureticus. — This drug produces marked diuresis ; 
it should not be used with a weak heart or when the 
nephritis is acute ; it increases blood pressure by irritation 
of the vaso-motor system ; its action is rapid and transi- 
tory ; dose twenty to forty drops every three or four 
hours. 

Uva ursi. — Urine milky, slimy, yellow, purulent and 
bloody, or red, scanty, high-colored and acid ; painfulness 
and soreness in the region of the kidney ; uneasy feeling 
in the left thigh, with frequent desire to urinate ; the stream 
is small, and the bladder is emptied only with considerable 
effort ; pain and soreness in the left groin ; heavy pain in 
the lumbar region, with uneasiness in the bladder ; fre- 
quently required in pyelitis. 

Uranium nitricum. — Urine high-colored, containing 
uric acid, urates, phosphates, lithiate of ammonia, pavement 
epithelium, casts and mucus; urine acid when voided 
rapidly becoming alkaline and offensive, of a fishy odor. 
Specific gravity increased. Micturition increased in fre- 
quency, burning in the urethra. Sore pain in the vesical 
region in the evening. It has produced acute parenchy- 
matous nephritis, and is often useful in uricaciduria, as 
well as in glycosuria. 

Vesicaria communis. — Renal colic is often controlled by 
this remedy in suppression of urine ; it is often successful 
in reestablishing the kidney action. 

Zingiber. — Suppression of urine; incessant micturition; 
stranguary ; urine scanty, bloody and albuminous, with 
other symptoms of acute nephritis. 



CHAPTER XXVIII. 

THE EXAMINATION OF URINE. 

Contributed by Ephraim D. Klots, M. D. 

When disease of the kidney exists, and the urinalysis is 
made to note the progress as well as the condition of the 
case under supervision, the specimen examined must be a 
part of the total quantity passed in twenty -four hours, and 
the quantitative analysis must be based on the whole 
amount. 

At the first examination it is determined that there 
is a particular kidney lesion. All subsequent examinations 
are for determining the condition of the kidney structure, 
and equally important, if the kidneys are performing their 
function as they should. 

By careful comparison, the quantity of the normal con- 
stituents which the kidneys should secrete each day has 
been accurately determined. If quantitative analysis is 
made of the total amount passed in twenty-four hours, it is 
not difficult to ascertain to what extent the kidneys are de- 
ficient in their secreting power. If a given specimen is 
simply examined without regard to the quantity, it may 
be possible to determine its abnormal constituents ; but as 
to proper or improper secretion, it is impossible. 

Quantity. — The normal quantity ranges from one litre to 
a litre and a half in twenty-four hours. In health, how- 
ever, depending on the amount of liquids ingested, the 
quantity may be as low as one-half litre or as high as two 
or three litres. 

Polyuria is a pathological increase in the quantity. 



340 UROPOIETIC DISEASES. 

In diabetes mellitus or insipidus, the quantity may be as 
high as fifteen litres, or even more. 

In chronic interstitial nephritis and amyloid disease of 
the kidney, polyuria is a prominent symptom. The 
quantity is never so high as in diabetes. 

Hysterical nervous conditions are often accompanied by 
an excessive flow of pale urine, and the same phenomenon 
is often observed during the rigor preceding intermittent 
fever. 

Oliguria is a decrease in the quantity. 

In the acute and chronic forms of parenchymatous 
nephritis, suppurative nephritis, tubercular nephritis and 
malignant diseases of the kidney, the quantity of urine is 
decreased. 

During the course of infectious fevers the flow is often 
scanty and at times may even be suppressed. 

Oliguria may also result from mechanical reasons, as the 
pressure of tumors or ascitic fluid on the renal vessels, 
which interferes with renal circulation. 

Anuria, or complete suppression of urine, sometimes oc- 
curs in acute nephritis or in the acute exacerbations of the 
chronic parenchymatous types, and more especially in the 
cases where there is rapid destruction of the parenchyma 
of the organ. It may occur in acute degeneration of the 
kidney caused by the ingestion of irritant poisons. 

Complete suppression has been known to occur in 
nervous hysterical subjects, and in those who are suffering 
from extreme mental anxiety. 

When the suppression is due to disease of the kidney it 
cannot continue long without the appearance of ursemic 
symptoms. On the other hand, when neurotic in origin, 
the uraemia may be delayed for a remarkable length of 
time. 

Color. — The natural color of urine varies from a pale 
yellow to a deep amber and is due to the presence of urobilin 



THE EXAMINATION OF URINE. 341 

and uroerythrin. The intensity of the color varies directly 
as to the quantity passed in twenty-four hours. When 
plentifully secreted it is light, and when scanty it is dark. 

In febrile conditions it is, as a rule, quite dark. This is 
due to concentration. Bile colors it brown. Blood, ac- 
cording to the amount present, pink, red, or if decomposed, 
a brownish red. 

In alkaline urine the earthy phosphates which have 
been precipitated render it opaque. The presence of 
chyle makes it look creamy. Bacteria cause a turbidity 
which filtering does not clear up. 

The ingestion of various drugs alter the color. Some of 
the coal-tar products color it brown and others pink. 

In diabetes or in cases of polyuria from any cause the 
urine is pale in proportion to the increase in quantity. 

Specific Gravity. — The normal specific gravity is from 
1018 to 1020. If the kidneys are performing their secret- 
ing function normally, the specific gravity varies directly 
as to the quantity, the more urine secreted the lower the 
specific gravity. 

In acute febrile conditions, where the secretion is scanty, 
the specific gravity is high, 1024 to 1028. In diabetes 
mellitus it is always high, 1028 to 1035, and even higher. 

In the parenchymatous forms of nephritis it is low, some- 
times as low as 1004. In chronic interstitial nephritis it 
is low, from 1010 to 1014, but this is generally compensa- 
ted by the polyuria. A continued oliguria with low spe- 
cific gravity, as a rule, lead sooner or later to symptoms of 
uraemia. 

Reaction. — The chemical reaction of a twenty-four hour 
specimen of normal urine is acid. Some urinations, es- 
pecially during the digestion of a hearty meal, may be 
alkaline. 

The acidity is due to acid sodium phosphates and urates. 

A vegetable diet diminishes the acidity ; an animal diet 
increases it. 



342 UROPOIETIC DISEASES. 

The ingestion of mineral acids increase the acidity ; the 
vegetable acids are excreted as alkaline carbonates and 
render the urine alkaline. The strongly alkaline chemicals, 
such as carbonate of sodium and potassium, render it 
alkaline. 

In inflammation of the bladder the growth of bacteria 
acts on the urea, and free ammonia is liberated rendering 
the urine alkaline. 



CHAPTER XXIX. 
CONSTITUENTS OF NORMAL URINE. 

Contributed by Ephraim D. Klots, M. D. 

Urea. (NH 2 ) 2 CO. — Urea is the principal constituent of 
the urine of man and carnivora. The urine of herbivora 
only contains a small amount. It is the product of the 
oxidation of proteids and albuminoids. 

In a healthy man living on a mixed diet the daily ex- 
cretion varies from 20 to 35 grammes (300 to 525 
grains). 

Varying conditions in health alter this quantity 
materially. The ingestion of large quantities of meat in- 
creases it, and the urine of a vegetarian shows a small per- 
centage. Physical exercise in excess tends to increase 
tissue waste and the amount of urea excreted. The re- 
verse is true of sedentary living. In disease, febrile con- 
ditions which increase metabolism raise the percentage. 
In the various forms of nephritis the excretion of urea is 
diminished. If its excretion is interfered with for any 
considerable length of time, uraemic poisoning occurs. 

Detection : Urea nitrate test. On a glass slide place a 
drop of urine. Across the drop lay a fine thread. Over 
this place a cover glass. At the spot where the one end of 
the thread passes from beneath the cover glass add a drop 
of nitric acid. Examined under the microscope crystals of 
nitrate of urea will be seen to have formed around the mar- 
gins of the thread. They are white, four or six-sided 
rhombic plates which overlap each other. 

Quantitative analysis : Many tests for determining the 



344 UROPOIETIC DISEASES. 

quantity of urea have been devised. The hypobromite 
method in connection with Dr. Doremus's apparatus is the 
most satisfactory and by far the simplest. This test de- 
pends on the fact that when urea is oxidized the hydrogen 
is converted into H 2 and the carbon into C0 2 , the 
nitrogen remaining unchanged. If the test is made in the 
presence of a strong alkaline medium, this will absorb the 
C0 2 , and the only gas evolved will be nitrogen, each c.c. 
of which equals 0.00282 gramme of urea decomposed. 

Dr. Doremus's apparatus consists of a bent tube that will 
retain the test solution when upright. The tube is 
graduated so that after the test is made the percentage of 
urea may be read at the bottom of the column of nitrogen 
which has displaced the solution. 

The solution and test is made as follows : Dissolve too 
grammes of caustic soda (NaOH) in 250 c.c. of water. 
Bach time the test is made 1 c.c. of bromine is dissolved 
in 10 c.c. of this caustic soda solution, and enough water is 
added to make up about 30 c.c. This is placed in the bulb 
of the apparatus, which is tilted, allowing the solution to fill 
the tube. With the graduated pipette 1 c.c. of urine is slowly 
forced into the solution at the bottom of the tube, which is 
held upright. When the urine comes in contact with the 
hypobromite the urea immediately begins to decompose 
and the nitrogen is evolved. When the last drop of urine 
has passed from the pipette it should be withdrawn, and 
the tube set aside for a few minutes. The percentage of 
urea may then be read off. 

Specific gravity method : The per cent, of urea may be 
roughly estimated to be the same as the last two figures of 
the specific gravity. Thus urine having a specific gravity 
of 1015 would contain iyi per cent, of area, 1030 specific 
gravity, 3 per cent, urea, etc. The presence of an excess 
of other normal constituents, or albumin or glucose, 
renders this method absolutely uncertain. 



CONSTITUENTS OF NORMAL URINE. 345 

Other tests in common use are Liebig's mercuric nitrate 
test, and the differential specific gravity method. 

Uric acid (C 5 H 4 N 4 3 ) : Uric acid is always found in the 
urine in small quantities. It is excreted much more abund- 
antly by the lower animals than by man. Chemically, it 
seems to bear close relation to urea, and by some is consid- 
ered to be the result of improper oxidation of proteids, the 
waste product being excreted as uric acid instead of urea. 
Urea fed to birds and snakes is excreted as uric acid. 

It is very sparingly soluble in cold water, and somewhat 
more so in hot water, and is seldom found in urine in its 
free state. It readily enters into combination with potas- 
sium, sodium and ammonium to form urates. 

The presence of uric acid crystals in urine does not imply 
an increase in the normal quantity. Any urine standing 
long enough will precipitate uric acid or urates. 

During the process of alkaline fermentation, uric acid 
combines with the ammonia to form ammonium urate. 

The daily elimination ranges from 0.2 to 1 gramme (3 
to 15) grains. The amount excreted is increased in acute 
fevers, in leukemia, phosphorus poisoning and some of the 
nervous diseases. It is diminished in nephritis, anaemia, 
lead poisoning, diabetes mellitus and after the ingestion of 
alcohol or quinine. In rheumatism and gout the excretion 
is very irregular; at times there is a marked increase, and 
at others the percentage is much diminished. 

Detection : When uric acid has precipitated in urine the 
microscope will readily reveal it. The crystals arrange 
themselves in varying groups, or may appear singly. They 
vary greatly in size and shape, the smaller ones needing 
the microscope to discern them, the larger ones being very 
evident macroscopically as brick dust deposit. (See plate 
x, figs. 1, 2 and 3.) 

Quantitative analysis : Heintz's method. To 200 c.c. of 
of urine add 10 c.c. of hydrochloric acid. Allow this to 



346 UROPOIETIC DISEASES. 

stand in a cool place for twenty-four hours. Collect the 
uric acid crystals which have precipitated on a previously 
weighed filter, and wash with distilled water. Dry the 
filter and crystals thoroughly in a dessicator and weigh. 
Subs tract the weight of the filter, and the remainder is the 
weight of the uric acid, 200 c.c, of the urine. Before the 
test is made, the urine should always be filtered, and if 
albumin is present it should be removed. 

Chlorides. — Next to urea the chlorides form the principal 
solids of the urine. The daily elimination ranges from 10 
to 16 grammes (150 to 240 grains). The chlorides of the 
urine are the chlorides of sodium, potassium and ammo- 
nium, principally the chloride of sodium, only a trace of 
the others being present. The quality and quantity of 
food has a marked influence on the elimination of chlor- 
ides. A salty diet greatly increases it. In the acute fevers, 
especially if accompanied by exudative inflammation, they 
are greatly diminished, and the progress of the disease 
toward recovery may be watched by recording their in- 
crease. In pneumonia, when there is a complete absence 
of the chlorides in the urine, the prognosis is apt to be 
grave. 

Detection : Acidulate some urine in a test tube and add 
about half a dram of a solution of silver nitrate 3i to 
gi. If chloride of sodium is present a curdy precipi- 
tate will form which is soluble in ammonia, but insoluble 
in nitric acid. 

Quantitative analysis : Purdy's centrifugal analysis is, per- 
haps, the most satisfactory. Purdy's tubes are graduated 
from the bottom of the tube up to the 10 c.c. mark, so that 
the percentage of any precipitate which is formed may be 
conveniently read off. The urine to be analyzed should 
fill the tube as high as the 10 c.c. mark; the space between 
the 10 c.c. and the 15 c.c. is for the reagent. In order to 
make an accurate analysis the precipitate should be 



PLATE X. 




- 



Fig. 2 






ric Acid, large crystals X 50 


Uric Acid, medium crystals X 75 


Fig. 3 




Fig. 4 




JH9 



VA 






•% 



*7^K 



Uric Acid, small crystals X 150 
Fig. 5 



Ti _ ipl£ Phosphate X 200 
Fig. 6 




Oxalate of lime, octahedral X 600 Oxalate of lime, anular and dumbbell \ 



CONSTITUENTS OF NORMAL URINE. 347 

thoroughly packed in the bottom of the tube. To do this 
the centrifuge should revolve at a rate of 1000 revolutions 
a minute for three minutes. 

Test for chlorides : Fill the tube to the 10 c.c. mark 
with the urine. Add a silver nitrate solution si to gi as high 
as the 15 c.c. mark. Place in the centrifuge and when 
thoroughly packed read off the percentage. Bach sub- 
division of the graduated scale represents 1 per cent, by 
bulk. The normal percentage of the chlorides by bulk by 
centrifugal analysis is from 16 to 18 per cent; any deviation 
from this can readily be determined. 

Phosphates. — The daily elimination of phosphoric acid 
(H 3 P0 4 ) ranges from 2.3 to 3.5 grammes (35 to 50 grains), 
the average being 2.8 grammes (40 grains). It occurs in 
combination with the soluble phosphates and the insoluble 
or earthy phosphates. 

The soluble phosphates are acid sodium phosphates, 
which give the urine its acidity, and potassium phosphate. 
They are present in larger proportion than the earthy 
phosphates and are never precipitated. 

The earthy phosphates are insoluble in water, but readily 
soluble in acids. In acid urine they are held in solution, 
the least alkalinity precipitates them. This is more 
marked if heat is applied. This fact may lead to error in 
making the heat test for albumen, as the urine may cloud 
by the precipitation of phosphates when the urine is boiled. 
Acidifying will redissolve them and clarify. 

As mentioned in a previous chapter, the action of the 
growth of certain bacteria on urea breaks up this com- 
pound and liberates free ammonia. The acid magnesium 
phosphates are acted upon by the ammonia forming am- 
monio-magnesium or triple phosphates, which crystallize in 
the form of fern-like particles, or more commonly in 
prismatic coffin-lid shaped crystals of varying size. (See 
plate x, fig. 4). 



348 UROPOIETIC DISEASES. 

The elimination of phosphoric acid is diminished in 
acute fevers, gout, during pregnancy, and in all forms of 
nephritis. It is increased in some nervous diseases and 
diseases of bone, rickets, osteomalacia, etc. 

Tessier has described a disease characterized by a marked 
excess in the excretion of phosphates. Clinically, the 
symptoms resemble diabetes mellitus, and he called it 
phosphatic diabetes. 

Detection : The earthy phosphates are precipitated by 
adding an excess of ammonia. The crystals formed when 
precipitated, hastily this way, are generally the fern-like 
variety, together with amorphous phosphates. 

Quantitative analysis of phosphoric acid : The following 
solutions are necessary for the test : 

i. A standard solution of uranium nitrate, containing 

20.3 grammes of pure uranium nitrate dissolved in 1000 

c.c. of distilled water. Each cubic centimetre of this 

solution corresponds to 5 milligrammes of phosphoric acid. 

2. A solution of sodium acetate, containing sodium 

acetate 100 c.c. dissolved in 900 c.c. of distilled 

water, to which 100 c.c. of acetic acid are added. 

3. A saturated solution of potassium ferro- 

cyanide. 

Pour 50 c.c. of the urine to be tested into a 
beaker and add 5 c.c. of the sodium acetate so- 
lution. Heat this mixture in a water bath. 
Fill a graduated 50 c.c. pipette with the urani- 
um nitrate solution. Allow this to flow into 
the heated mixture in the beaker, drop by 
drop, as long as a precipitate is formed. On a 
white porcelain dish place twenty or thirty 
drops of the ferrocyanide of potassium solution. 
During the latter part of the test, the solution 
in the pipette should drop very slowly, that the test may 
beacurately made. From time to time with a glass rod 



CONSTITUENTS OF NORMAL URINE. 349 

take up a drop of the mixture and place it against one 
of the drops of the ferrocyanide solution on the dish. Just 
as soon as a brown color is apparent at the junction of 
the two drops the test is complete. The number of cubic 
centimetres of the uranium solution required to complete 
the test multiplied by five, equals the number of milli- 
grammes in 50 c.c. of urine. The percentage may easily 
be deducted. 

To determine the percentage of phosphoric acid of the 
earthy phosphates, precipitate them by the addition of 
ammonia and collect on a filter paper after washing 
with a solution of ammonia 1 to 3. The filter is punctured 
and they are now washed down into a beaker and dissolved 
in a weak solution of acetic acid. When thoroughly dis- 
solved enough water is added to make up 50 c.c; 5 c.c. 
of the sodium acetate solution are added and the test pro- 
ceeds as above. 

Carbonates. — Urine contains a small quantity of carbonic 
acid gas. It also contains traces of sodium, potassium, and 
magnesium carbonate. They are derived from food contain- 
ing lactic, tartaric, malic succinic, and other vegetable acids. 
Ammonium carbonate is often found in large quantities in 
urine which has stood for a long time. It is the result of 
the decomposition of urea. 

Detection : The addition of an acid to urine which con- 
tains carbonates liberates carbonic acid gas which renders 
lime water turbid. 

Sulphates. — In normal urine the percentage of sulphates 
bears a close relation to the percentage of urea. Their 
elimination amounts to from 1.5 to 3. grammes (22)4 to 
45 grains) in twenty- four hours. They are derived chiefly 
from the proteid food stuffs. They are increased after the 
ingestion of sulphuric acid or its salts, from excessive 
ingestion of meats and from any cause which tends to 
increase oxidation. 



350 UROPOIETIC DISEASES. 

Detection : Acidify some urine in a test tube with a few- 
drops of hydrochloric acid and add about one-third its 
volume of barium chloride solution ; barium chloride four 
parts ; hydrochloric acid, one part, and water, sixteen parts. 
A milky precipitate denotes a normal quantity of sul- 
phates ; a faint cloudiness, a decreased quantity ; a thick 
creamy precipitate an increase. 

Oxalic acid. — Oxalic acid is found in the urine in the 
form of Calcium oxalate. (See plate x.) It is eliminated 
normally in quantities ranging from o.oi to 0.02 gramme 
in twenty-four hours. It is often precipitated before the 
urine is voided. It appears in the form of octahedral, 
anular and dumb-bell crystals ; the octahedral crystals vary 
considerably in size. It is increased by a vegetable and 
fruit diet. It often appears in abundance in the urine 
of subjects who are indolent in their habits and suffer 
indigestion. When the elimination is excessive for a con- 
siderable length of time symptoms of irritation to the 
genito-urinary tract and constitutional disturbances are 
apt to appear. Calculi composed of oxalate of lime 
may form in the pelvis of the kidney or in the bladder. 

Many other compounds are found in the normal urine, 
but clinically they are of little import and their study is be- 
yond the scope of this article. 



CHAPTER XXX. 
CONSTITUENTS OF ABNORMAL URINE. 

Contributed by Ephraim D. Klots, M. D. 

Albumen : In normal urine there exists faint traces of 
nucleo-albumen which is probably taken up from the lining 
epithelium of the glomeruli and tubules of the kidney 
after the urine has been secreted, and is in no way indica- 
tive of malsecretion. 

There may be a perceptible albuminuria following the 
ingestion of large quantities of albumin. Excepting these 
two instances, it may be said that albuminuria is always 
pathological. There are individuals in whose urine from 
time to time albumen is found, with absolutely no other 
indication of kidney lesion. There must be, however, some 
faulty condition of the secretive function, and, as Delafield 
says, these cases are of poor lives, and must always be 
looked upon with suspicion, and their kidneys should be 
carefully watched for more evident manifestation of a per- 
haps oncoming nephritis. 

In all forms of nephritis or degeneration of the kidneys, 
there is present an albuminuria of greater or less degree. 
In the acute and chronic forms of parenchymatous 
nephritis the quantity may, at times, be very large, but 
never to exceed 3 per cent, by actual weight. In chronic 
insterstitial nephritis the quantity is never large, and for 
long periods may be absent altogether. 

The quantity of albumen present in the urine of ne- 
phritis is greatly influenced by the condition of the circu- 
lation generally. If there is a co-existing endarteritis, and 
the right ventrical of the heart is not sufficiently hyper- 



352 UROPOIETIC DISEASES. 

trophied to compensate, the albuminuria may be far in 
excess of the amount one would expect from the existing 
kidney lesion. 

Febrile albuminuria has been described as that which 
occurs during the course of acute fevers. 

Toxic albuminuria is supposed to be due to the irritat- 
ing effect on the kidney structure of the toxins, which are 
the result of bacterial growth. 

Albuminuria often results from the ingestion of irritant 
poisons. 

Any influence which materially alters the circulation of 
the kidney, causing passive congestion, may produce an 
albuminuria. This may be due to an insufficient heart's 
action, from a general endarteritis, or from local causes 
such as the pressure of tumors on the renal vessels. 

Detection : The nitric acid ring test, Heller's test : Pour 
about a drachm of strong nitric acid into a small test tube. 
Incline the tube and allow an equal quantity of the urine 
to slowly trickle down the side of the tube and over the 
surface of the acid. Inspect in a strong light against 
a black background. If albumen is present there will 
appear at the junction of the two liquids a white opaque 
ring. The test should not be considered final unless the 
ring fails to appear at the end of an hour. 

Heat test: This test depends on the coagulation of 
albumen by heat. Half fill a test tube with the urine 
which has previously been filtered absolutely clear, and 
acidify with two or three drops of acetic acid. Over the 
flame of a Bunsen burner or alcohol lamp boil the upper 
half of the column of urine. Note if the portion which 
has been boiled has become cloudy. If so, boil the whole 
specimen and add one or two drops of nitric acid. If the 
cloudiness is due to the precipitation of earthy phosphates, 
the urine will clarify ; if it remains turbid, albumen is 
present. 



CONSTITUENTS OF ABNORMAL URINE. 353 

If pine acids are present in the urine, as after adminis- 
tration of cubebs or copaiva, a cloudiness will appear. 
They may be detected by their odor. The addition of 
alcohol will dissolve them and clarify the urine. 

Picric acid test : A test tube is nearly filled with urine. 
Inclining the tube as in the nitric acid ring test, a little of a 
saturated solution of picric acid (about seven grains to the 
ounce) is allowed to flow over the urine, care being taken 
that the two liquids mix slightly. If albumen is present 
cloudiness will appear in the zone where the liquids inter- 
mingle. Albumen, mucin, peptone and vegetable alka- 
loids respond to this test but the application of heat dis- 
solves all but the albumen. 

Quantitative analysis : The gravimetric method : A 
mixture of equal parts of a saturated solution of potassium 
ferrocyanide and acetic acid is added drop by drop to 100 
cc.of the urine until all the albumen has been precipitated. 
The precipitated albumen is collected on a previously 
weighed filter and washed with distilled water, alcohol 
and ether in succession, and dried in a dessicator. The 
whole is then weighed and the weight of the filter is sub- 
tracted from the result. The remainder is the weight of 
the albumen in 100 c.c. of the urine. 

Esbach's method : This method determines the percent- 
age by bulk. The standard solution is made up as fol- 
lows : Picric acid 10 gms., Citric acid 20 gms., distilled 
water 1,000 c.c. The urine is poured into the tube as 
high as the mark U and the reagent is added as high as 
the mark R. The tube is then closed with the stopper 
and the fluids are thoroughly mixed. It is set aside in an 
upright position for twenty-four hours. The height of the 
precipitated albumen may now be read off. Bach sub- 
division of the scale is equal to one gramme of albumen to 
the litre of the urine, and the result divided by ten equals 
the percentage. Thus, if the column of albumen is eleven 
23 



354 UROPOIETIC DISEASES. 

subdivisions of the scale high, the number of grammes of 
albumen to each litre is eleven and the percentage is o.n. 

The Centrifugal method : This method accomplishes the 
same as the preceding much more quickly and accurately. 
The graduated tube is filled to the 10 c.c. mark with the 
urine, and over this is poured to the 15 c.c. mark, a mixture 
of Acetic acid 1.5 c.c. and 3.5 c.c. of a 10 per cent, solu- 
tion of Potassium ferrocyanide. The urine and reagent are 
thoroughly but gently mixed and the tube is revolved in 
the centrifuge until the precipitate is thoroughly packed 
in the bottom. The percentage is read off at the top of 
the column of the precipitate, each subdivision of the 
scale being equal to one per cent. 

It must be remembered that the percentage by bulk as 
determined by the last two methods is by no means the 
same as the actual per cent, by weight as determined by 
the gravimetric method, but they are much more con- 
venient and require considerably less time and care, and 
if used by comparison will answer all practical purposes. 

Globulin. — From }i to -^ of the albumen found in 
urine consists of globulin. In hsematuria and amyloid 
disease of the kidney it exists in much larger proportion, 
and as a means of diagnosis in the latter it is important to 
determine its proportion to the serum-albumen. The 
globulin is precipitated and its quantity is determined. 
The quantity of total albumen is also determined, when the 
ratio of the two is easily deducted. 

Carefully neutralize 100 c.c. of the urine and add mag- 
nesium sulphate to saturation. The precipitate formed is 
globulin. Collect the precipitate on a previously weighed 
filter and wash with distilled water. Dry thoroughly in 
a dessicator, weigh the whole and subtract the weight of 
the filter from the result. The remainder is the weight of 
the globulin in 100 c.c. of the urine. Subtract this from 
the weight of total albumen in the same quantity of urine, 



CONSTITUENTS OF ABNORMAL URINE. 355 

and the remainder is the weight of the serum-albumen. 
Having now determined the respective weights of both 
albumens in a given quantity of urine, the ratio is apparent. 

Haemoglobin. — Hsemoglobinuria is the result of the 
destruction within the blood vessels of the red cells. 

This may be caused by transfusion into the circulation of 
water, glycerine, a subnormal salt solution or the blood of 
some other animal, from poisoning by phosphorus, carbolic 
acid, pyrogallic acid, potassium chlorate or arseniated hydro- 
gen. It may also occur after extensive burns, and at times 
accompanies extreme jaundice, typhus fever, malaria, 
scurvy, pyaemia and purpura. When liberated into the 
blood plasma it is always seen in the urine. 

Detection : Guaiacum test : Mix together in a test tube 
equal quantities of tincture of guaiacum and old turpentine 
which has been thoroughly oxidized by exposure to the 
air. To this add the urine as in the nitric acid ring test, 
by pouring carefully down the side of the tube. If 
haemoglobin be present a blue ring appears at the junction 
of the two liquids. On shaking, the whole mixture 
becomes blue. If the urine contains pus this reaction also 
takes place, but on heating the blue color disappears. 
Urine containing pus responds to this test with the tinct- 
ure of guaiacum alone. 

Heller's test : Render the urine strongly alkaline by the 
addition of sodium hydrate and boil. The precipitate of 
the earthy phosphates will be colored red by hsematin. 

Glucose. — A faint trace of grape sugar exists in normal 
urine, but its presence may not be considered pathological 
unless it can be detected by the ordinary clinical tests. 

Glycosuria is the predominating symptom of diabetes 
mellitus. The amount secreted in a day may be tremen- 
dous. Two to three gallons of urine may be secreted in 
twenty-four hours, containing so much sugar as to make 
it almost syrupy. 



356 UROPOIETIC DISEASES. 

It may occur temporarily in neurasthenia and melan- 
cholia, and has been demonstrated in obesity, acute 
malarial fever, cholera, gout, and in some cerebral lesions, 
especially those occuring in the region of the fourth ven- 
tricle. 

In gouty subjects after a debauch it often appears as a 
transitory symptom. 

When sugars have been secreted beyond the quantity 
which the organism can care tor, the excess appears in the 
urine. 

A transient glycosuria may follow the ingestion of cer- 
tain substances i. e., turpentine, uranium nitrite, chloral 
hydrate, tannic acid, hydrocyanic acid, carbolic acid, 
benzol, phloridzin, and amyl nitrate. 

Uric acid, creatinin, the coloring agents of urine, and 
bile when present, are capable of reducing copper sulphate 
in the presence of an alkali. 

Detection: Haines' test: The solution is made up as 
follows : Dissolve thoroughly in one-half ounce of distilled 
water thirty grains of pure copper sulphate, and add one- 
half ounce of pure glycerine ; mix thoroughly and add five 
ounces of liquor potassse. 

Pour about one drachm of the solution in a test tube and 
boil. Add from six to eight drops of the suspected urine 
and boil gently again. If sugar be present, a copious 
yellow precipitate is thrown down. If the mixture re- 
mains clear, sugar is absent. 

Phenylhydrazin test : This is an exceedingly delicate test, 
and is exceptionally valuable from the fact that it is not 
influenced by the substances which have a tendency to re- 
duce copper. The test is conducted as follows : 

Pour 20 c.c. of the suspected urine in a test tube and 
add 0.5 gm. of phenylhydrazin hydrochloride and 0.3 gm. 
of sodium acetate. Place the mixture in a water bath and 
heat for an hour. If sugar be present a glistening, crystal- 



PLATE XI. 



Fig. 1 



Ammonium Urate X 600 



Fig. 3 



Fig. 2 




Cystine X 40* 
Fig. 4 



Oxalate of Urea X 400 
Fig. 5 



X 



Cholestrin X 400 
Fig. 6 




Tyrosine X 400 



Phenylglucosazone X 450 



CONSTITUENTS OF ABNORMAL URINE. 357 

line, yellow precipitate will be formed which, under the 
low powers of the microscope, appears as long yellow 
needles (phenylglucosazone) arranged singly or in fan-like 
formations (See plate xii.). Yellow spheres or scales have 
no bearing on the test, only the long yellow needles. Care 
should be taken not to let the phenylhydrazin come in 
contact with the skin, as it produces an irritating eczema. 
Quantitative analysis : Purdy's test : The formula for the 
standard solution is as follows: Cupric sulphate (C. P.), 
4.742 gr.; potassium hydroxid (caustic potash) (C. P.), 
23.50 gr.; strong ammonia (U. S. P.), (sp. gr., 0.9), 450 
c.c; distilled water to 1000 c.c. glycerine (C. P.), 38 c. c. 

Prepare by dissolving the cupric sulphate and glycerine 
in 200 c.c. of the distilled water with the aid of gentle 
heat. In another 200 c.c. of distilled water dissolve the 
potassium hydrate. Mix the two solutions, and when cold 
add the ammonia. Finally with distilled water bring the 
volume of the whole to exactly 1000 c.c. Thirty-five c.c. 
of this solution are reduced upon boiling by exactly 2 centi- 
grammes of grape sugar. 

The analysis should be conducted as follows : Have on 
hand a glass flask of about 200 c.c. capacity, a 
common retort stand, a 10 or 20 c.c. graduated 
burette, and a large spirit lamp. 

Accurately measure 35 c.c. of the solution 
into the flask, dilute with about two volumes 
of distilled water, and bring the whole thor- 
oughly to the boiling point. Fill the burette 
to the zero mark with the urine to be tested, 
and slowly, drop by drop, discharge the urine 
into the boiling solution, until the blue color 
begins to fade ; then still more slowly, three to 
five seconds elapsing between each drop, until 
the blue color has completely disappeared and 
the test solution is left perfectly colorless and transparent 



rf^W 




358 UROPOIETIC DISEASES. 

The number of c.c. of urine it requires to eradicate the 
blue color in 35 c.c. of the test solution contain exactly 
0.02 gramme of sugar. 

If 35 c.c. of the test solution is reduced by 2 c.c. of urine, 
there is exactly 1 per cent, of sugar reduced by 1 c.c, 2 per 
cent, reduced by ^ c.c, 3 per cent, reduced by y 2 c.c, 
4 per cent, reduced by % c.c, etc. 

Fermentation method : This method depends on the loss 
of specific gravity after fermentation has taken place. The 
test is conducted as follows: Almost fill two bottles, holding 
about four ounces, with the urine. In one of them dissolve 
one-sixteenth of a cake of yeast. Cork the bottles with a 
plug of cotton and set aside in a moderately warm place 
for twenty-four hours. By this time fermentation will 
have ceased. The specific gravity of each is now deter- 
mined. Each degree of difference between the two repre- 
sents one grain of sugar to the ounce of urine tested. The 
percentage may be approximately ascertained by multiply- 
ing the number of degrees difference by 0.23. 

Mucin may be present in normal urine in small 
quantities. It appears in large quantities in severe cases of 
cystitis and pyelitis. When abundant it is seen in a 
stringy, tenacious mass. 

Detection : Dilute the urine with an equal quantity of 
water, and add an excess of acetic acid. The precipitate is 
mucin. 

Bile. — Bile pigments are present in the urine in all con- 
ditions which are accompanied with jaundice. Even when 
the skin and conjunctivae fail to show discoloration, the 
tests for its presence in urine may reveal it. Poisoning by 
phosphorus or aniline is followed by a presence of bile in 
the urine. 

Bile colors the urine a greenish yellow. When shaken 
the froth is also discolored. - Any anatomical sediments 
which may be present in urine, which contains a moderate 



CONSTITUENTS OF ABNORMAL URINE. 359 

quantity of bile, will be stained a pale brown, which 
renders them more easily discernible. 

Detection : Gmelin's test : Pour into a test tube about a 
drachm of fuming nitric acid, and allow some of the urine 
to flow gently over it. A green band will be seen at the 
junction of the two liquids, and from below upwards blue, 
violet, red and yellow. The test may also be made by 
pouring some of the urine on a shallow dish and dropping 
a few minims of fuming nitric acid in the center of the 
urine. When the same display of colors will be seen 
around the acid if bile is present. 



CHAPTER XXXI. 

THE CLINICAL SIGNIFICANCE OF URINARY 
DEPOSITS. 

Contributed by Ephraim D. Klots, M. D. 

Normal urine generally contains a small amount of sedi- 
ment which consists of various organic and inorganic 
substances. It may, however, be entirely free from sedi- 
ment of any kind. If the urine is to be kept for any con- 
siderable length of time, ten drops of formaline to each 
ounce should be added. Greater accuracy is assured if the 
precipitate is collected by the aid of a centrifugal machine. 
When the sediment has been precipitated by centrifuga- 
tion, and the overlying clear urine decanted, the precipitate 
should be thoroughly agitated before any portion of it is 
removed for microscopical examination, otherwise only a 
portion of the whole may be seen, as the different in- 
gredients are precipitated according to their different 
densities. 

Blood : In small quantities blood may not discolor the 
urine, and its presence may only be determined by micro- 
scopical examination. Its presence in urine indicates either 
inflammation or injury to some portion of the genito- 
urinary tract. Hsematuria, due to traumatism, may be due 
to external violence or to the presence in the kidney of some 
irritating substance, as a calculus, directly causing abrasion 
of the mucous surface. Degeneration of the walls of the 
blood vessels and their subsequent rupture is a cause of 
hsematuria. The presence of new growths in the kidney 
is a prime factor in the cause of hsematuria. 



SIGNIFICANCE OF URINARY DEPOSITS. 361 

In order to determine the source of blood found in the 
urine we must associate the other ingredients and take into 
consideration the clinical symptoms. 

Blood cells in urine can hardly be mistaken for any 
other structure. They are small bi-concave discs of a 
yellowish color, non-nucleated and symmetrical. As a rule, 
unless the haemorrhage has been profuse and the percent- 
age of blood is in consequence large, the red blood cells do 
not arrange themselves in rouleaus as they do in specimens 
of freshly-drawn blood. Their characteristic contour can 
be mapped out by careful manipulation of the fine adjust- 
ment of the microscope. The smooth, round periphery of 
the cell will at one time be in focus, at another the thinned- 
out center. If seen on edge the cell will have a dumb bell 
appearance, and may be mistaken for some of the crystals 
found in urine which assume this shape. 

If red blood cells have existed in a very acid urine for a 
considerable length of time, they shrivel or crenate and 
lose their characteristic shape. In this case, however, they 
have liberated some of their haemoglobin and a test for 
this compound will clear up any doubt. 

Blood from the kidney, if present in sufficient quantity to 
perceptibly discolor the urine, gives it a brownish, smoky 
tinge. This is the general rule, especially if the blood 
is in moderate quantity and has had time to become 
thoroughly mixed with the acid urine, which is the cause 
of the discoloration. If, however, a haemorrhage from the 
pelvis of the kidney, either from a tumor or from severe 
injury, be profuse, and the urine is voided soon after its 
entrance into the bladder, the color may be bright red. 

Blood casts may form in the ureters. These are 
generally of a brownish red color, and indicate haemorrhage 
from the ureter itself or from the pelvis of the kidney. 
These have been mistaken for the Strongylus Gigas worm. 
Microscopic examination should clear up any doubt. 



362 UROPOIETIC DISEASES. 

In acute diffuse nephritis, acute productive nephritis, 
and the acute exacerbations of the chronic exudative types 
of nephritis, the urine may contain variable quantities of 
blood ; the associated presence of renal tube casts, especially 
casts containing blood, is an indication that the source is 
the kidney. 

In haemorrhagic nephritis or pyelitis where tubercular 
disease is suspected, the presence of tubercle bacilli will 
determine conclusively the cause. 

Whenever blood is present in the urine, there will also be 
leucocytes. It is a matter of importance to determine 
if the leucocytes present are due simply to the presence of 
blood or if there is also pus in the urine. Some of the 
urine should be thoroughly mixed and a drop placed on 
the Thoma-Zeiss hsemocy to meter for counting. If the 
number of leucocytes are far in excess of the physiological 
proportion to the number of red blood celis, i. e., 1-700, 
there is in all probability a co-existing pyuria. 

Urine containing blood must necessarily contain albumen, 
and it is important to determine if the quantity of albumen 
is in physiological proportion to the amount of blood 
present. Goldberg's method for differentiation is as 
follows : Thoroughly mix the urine and blood. With 
the Thoma-Zeiss hsemocytometer calculate the number of 
ceils in a cubic millimetre. Determine the percentage of 
albumen by bulk (Esbach's method) and divide the per cent, 
by the number of red cells in each cubic millimetre of the 
urine. If the result is less than -g-g-oVo- ^ e albuminuria 
is due solely to the blood. Example : In each cubic 
millimetre of a specimen of urine there was contained 
80,000 red blood ceils. The percentage, by bulk, of albu- 
men was y^ of one per cent. % divided by 80,000 equals 



cause of the albuminuria. 

Bright red blood and irregular shaped clots found in the 



SIGNIFICANCE OF URINARY DEPOSITS. 363 

urine are apt to come from the bladder. If, however, there 
is retention, the blood may become discolored and the 
kidney as a source suspected. In cystitis there is gen- 
erally a variable amount of blood in the urine and the cells 
retain their shape and density of color. 

Haemorrhage from the prostate or urethra colors the 
urine a bright red. Here, however, there may be excep- 
tions. If there is a stricture of small calibre anterior to 
the prostatic urethra and the haemorrhage takes place pos- 
terior to the stricture the blood may find its way back into 
the bladder, and, as there is very apt to be retention conse- 
quent upon the stricture, the blood may become discolored 
to resemble that which would come from the kidney. 

Blood may clot in the urethra. These clots are thicker 
and bright red in contradistinction to the long brownish 
clots which are cast in the ureters. 

Pus: Pyuria indicates an exudative inflammation in some 
portion of the genito-urinary tract. The amount of pus 
present is directly in proportion to the severity of the in- 
flammation. As a rule, the presence of any considerable 
amount of blood with the pus indicates an acute inflamma- 
tion. In the urine of females there appear a few stray 
pus cells, with no appreciative evidence of any inflam- 
matory lesion. These are very likely vaginal in origin. 

There is no way of determining, simply by the appear- 
ance of the pus cell itself, where the inflammation exists. 
In order to determine this we must take into consideration 
the associated particles in the sediment, the general 
urinalysis, and also the clinical observations. 

Generally speaking, pus in an alkaline urine comes from 
the bladder, and pus in an acid urine from some portion of 
the genito-urinary tract either above the bladder or below 
it. There are exceptions to this, however, which must be 
borne in mind. The pus may come from the kidneys, 
ureters or urethra, and from the ingestion of drugs the 



364 UROPOIETIC DISEASES. 

urine is alkaline. This is a common observance in gonor- 
rhoea when the aim of the surgeon is to keep the urine 
alkaline. It will be seen later that there are other charac- 
teristics which are peculiar to cystitis. 

In the exudative types of nephritis, especially the acute, 
there is generally a moderate secretion of pus and some 
red blood cells. The specific gravity is low. There is 
only a small amount of mucus and after sedimentation has 
taken place the urine is usually clear. The amount of 
albumin is more than the quantity of pus and blood would 
warrant, and the sediment also contains various forms of 
tube casts, and especially diagnostic are the casts contain- 
ing pus. 

During the first stage of pyo-nephrosis and suppurative 
nephritis there may be no pus in the urine, but on rupture 
of the abscess there will be a copious discharge of pus and 
necrotic tissue into the bladder. One of these fragments 
may be large enough to block up the ureter, when the 
pyuria will suddenly cease, to be resumed again when the 
pressure from retention is sufficient to force the plug 
through the ureter. The urine is generally acid, but if 
retained in the pelvis of the kidney for a considerable 
length of time it may undergo alkaline fermentation and 
present a neutral, if not acid, reaction. As in all abscesses, 
the pus cells may be degenerated, even so much so as to 
become unrecognizable. The fragments of necrotic tissue 
may be recognized as coming from the kidney. 

Injuries to the ureter, more especially after the passage 
of calculi, may be followed by infection, inflammation and 
pyuria. After excluding bladder or renal origin, the past 
history of the case and the presence of ureteral epithelium 
will aid in clearing up the diagnosis. 

In cystitis the pus is generally accompanied by much 
mucus, and the sediment is often in a jelly-like mass. The 
quantity of bladder epithelium in the urine is in propor- 



SIGNIFICANCE OF URINARY DEPOSITS. 365 

tion to the severity of the inflammation, but at all times 
there seems to be more than the lesion would warrant. 
In the severe forms the deeper layers of epithelial cells 
may be seen ; in the milder types only the large round 
superficial ones. In acute cystitis there may be a consider- 
able amount of blood present. 

The urine of cystitis is generally alkaline. In recent 
acute attacks it may be acid, but in old chronic cases it is 
never so unless from extraneous reasons the urine is 
voided from the kidney in an exceptionally acid state, and 
even then it shortly becomes alkaline. It has an am- 
moniacal odor and usually contains numerous crystals of 
triple phosphates. Bacteria are usually present in large 
numbers. In some severe types there may be present 
necrotic fragments of the bladder wall, especially if the 
cause is due to the presence of a vesical calculus. 

In cystitis accompanying papilloma, carcinoma or tuber- 
cular disease, fragments characterizing these lesions will be 
found in the sediment. 

An abscess formed in the structures surrounding may 
rupture into some portion of the geni to-urinary tract and 
give rise to a sudden and profuse pyuria. A careful study 
of the accompanying fragments will aid materially in de- 
termining its locality. 

In all cases of pyuria a bacteriological examination of 
the sediment should be made. This will be described under 
the sub-heading of bacteria in this chapter. 

Pus in the urine may be due to prostatic inflamma- 
tion. An abscess of the prostate may rupture into the 
bladder or urethra. In either instance the presence of 
prostatic epithelium or tissue will aid in determining the 
source. In catarrhal prostatitis groups of pus cells are 
often moulded into shreds, which resemble those that 
appear in chronic urethritis. They are generally voided 
with the first gush of urine, the remainder being clear. 



366 



UROPOIETIC DISEASES. 



Urethritis generally makes itself manifest, clinically, 
beyond the question of doubt. Pus from the urethra may, 
however, in strictured conditions of that canal, leak back 
into the bladder, and the urine will appear like that of 
cystitis. In truth, this cannot go on for long without 
infecting the bladder wall. 

Epithelium : A few squamous epithelial cells are almost 
always found in normal urine. In the urine of females the 
large squamous vaginal cells are constantly present. 

It is impossible to differentiate between the cells of the 
kidney pelvis, bladder and urethra, as they are all of the 
same type. The cells of the ureters are small spindled. 




a. a. Vaginal epithelium ; b. b. Bladder epithelium ; c. c. Kidney 
epithelium ; d. d. Epithelium from ureter. 

They resemble some of the bladder cells. The cells from 
the kidney tubules are small polygonal. They have a 
large nucleus and their bodies are quite granular. As 
they only appear as the result of disease, they are apt to be 
more or less degenerated. Associated with tube casts, or 
imbedded in their substance, all doubt may be excluded as 
to their origin. It is well to study these cells from sections of 
kidney tissue. In some instances, they are swollen ; in 
others, their bodies have so degenerated as to leave little 
else but the nucleus. Often they appear in groups. 



PLATE XII. 



Fig. 




Fig. 2 



Pus cells X yo( 
Fig. 3 



Blood cells X 700 
Fig. 4 



Hyaline casts X 600 
Fig. 5 



Granular casts X 600 
Fig. 6 



& N 



m0^ 



Epithelial casts X 600 



Fatty granular casts X 600 



SIGNIFICANCE OF URINARY DEPOSITS. 367 

Prostatic epithelium resembles renal epithelium. The 
cells of the prostate, however, are somewhat larger. 
^_ Tissue: When inflammation is severe enough to cause 
much necrosis, fragments of the degenerated tissue will 
appear in the urine. 

When new growths exist, fragments may tear away, and 
at times these are large and distinct enough to make a 
diagnosis ; but often the degeneration is so complete that 
it is impossible to recognize structure. 

In tubercular disease, cheesy masses, elastic fibres and 
fibrous tissue will appear from time to time. When this 
condition is suspected, the presence of tubercle bacilli will 
exclude all doubt. 

Dermoid cysts may ulcerate and empty their unmistak- 
able contents into the bladder. 

Tube casts: Hyaline casts are occasionally seen in urine 
otherwise normal. Their presence, however, indicates a 
pathological condition, even though it be only passive con- 
gestion. Their repeated occurrence is to be looked upon 
with suspicion, as a prodrome of something more serious 
to come. 

The appearance of hyaline casts with albumin indicates 
a mild nephritis. They are homogeneous and transparent. 
They may be short, long, thick or narrow. The ends are 
generally rounded, though one or both extremities may 
appear broken off. To the inexperienced observer they 
are hard to find and must be studied with a much 
bedimmed light thrown obliquely across the field. 

Epithelial casts denote a more severe form of nephritis. 
The lesion is severe enough to have caused a degeneration 
of the renal epithelium, which has become detached from 
the wall of the tubule and imbedded itself into the hyaline 
material forming the cast. 

Granular casts are the result of considerable degenera- 
tion, the granular matter being the debris resulting from 



368 UROPOIETIC DISEASES. 

degeneration of cells and exudate. They are light or 
dark, depending on the amount and character of the 
granular matter they contain. They are present in the 
parenchymatous and interstitial forms of nephritis. 

Fatty casts are the result of fatty degeneration of the 
parenchyma of the kidney, and are more generally found 
in the more chronic forms of nephritis. 

Waxy casts are rare. They are apt to be broken at one 
or both ends. They stain with iodine solutions. 

Pus and blood casts are generally the result of acute ne- 
phritis. Pure blood casts are rare. With pus and blood 
casts are generally associated epithelial casts. 

Bacterial casts are seen in septic nephritis. They are 
masses of bacteria and may be differentiated from granular 
casts by their power of taking up the analine dyes. 

Casts may contain various crystals formed in the kidney. 

It is well to determine if the structures are imbeded in 
the substance of the cast or merely adherent to its surface. 
This can be done by careful use of the fine adjustment 
under a moderately high power. 

Bacteria: Normal urine contains no bacteria. Under 
certain conditions, however, myriads of bacteria appear in 
urine which in every other way appears to be normal. 
These are non-pathogenic fungi, which have invaded the 
bladder and have found the urine a suitable culture 
medium for their growth. This condition has been 
named bacteriuria. 

Two varieties of fungi are found in the urine : Non- 
pathogenic, or those which are innocuous, and pathogenic, 
which give rise to disease. 

Among the non-pathogenic fungi, yeast molds are occa- 
sionally noticed in diabetic urine. They are only present 
when the urine is undergoing fermentation. 

Many forms of bacteria play an important part in am- 
moniacal fermentation of urine. Prominent among these 



SIGNIFICANCE OF URINARY DEPOSITS. 369 

are bacterium termo and micrococcus urea. Sarcinse are 
occasionally found in urine. 

Many of the pathogenic bacteria may exist in urine. 
Some of them give rise to local disease in some portion of 
the genito-urinary tract, and others simply appear in the 
urine during the course of a disease made manifest else- 
where. 

The pyogenic bacteria are found in pyo-nephrosis and 
septic nephritis. They have also been found in urine when 
the local manifestation of their growth exists in some 
other part of the body. 

Bacillus coli communis is commonly found in the urine, 
and in many instances seems to be an etiological factor in 
pyelitis and cystitis. 

The typhoid bacillus has repeatedly been found in the 
urine of typhoid fever patients. It has by no means been 
demonstrated in every case, however. 

The gonococcus of Neiser is always found in the pus of 
acute gonorrhoea. These cocci are not only found in the 
bodies of the pus cells and epithelia, but are found free in 
urinary sediment when gonorrhoea exists. In all cases of 
gonorrhoea the patient should never be discharged as 
cured until the pus shreds which are found in the urine, 
even for months or years after all urethral discharge has 
ceased, are absolutely free from this organism. 

In tubercular disease of the kidney, bladder, or any part 
of the genito-urinary system, the tubercle bacillus need 
necessarily be present. Sometimes it is found in large 
numbers, but often after repeated examinations, when 
there is all good evidence of existing tubercular disease, 
it cannot be found in the exudate. In these cases a guinea 
pig should be inoculated with a small amount of the 
sediment. At the end of three weeks it should be killed, 
and the contents of one of the enlarged lymphatics used to 
make a culture on agar-glvcerine or blood serum. If a 
24 



370 UROPOIETIC DISEASES. 

pure culture of the tubercle bacillus is obtained, the result 
of the experiment is conclusive. 

To examine urinary sediment for bacteria, cover glass 
preparations should be made as in the case of sputum, pus, 
etc. The following technique should be employed : Pre- 
cipitate the sediment with a centrifugal machine until 
thoroughly packed in the bottom of the tube. Pour off all 
of the urine and fill the tube again with distilled water. 
Mix the sediment with the distilled water and precipitate 
again as before. Pour off the water and the precipitate is 
ready for the cover glass. Sterilize a platinum wire in the 
flame of an alcohol lamp or Bunsen burner. With the 
sterilized platinum wire take up a portion of the precipitate 
not larger than the size of a pinhead, and smear it thinly on 
the center of the cover glass. When dry, take hold of the 
cover with a pair of self-closing forceps, smear-side up. 
Pass quickly through the flame of the lamp to fix the 
specimen to the glass. The smear is now ready for stain- 
ing. Most bacteria stain readily with the plain watery 
solutions of the analine dies. A good stock solution is a 
i per cent, solution of Gentian Violet in water. Enough 
of this is poured on the cover to well include the smear 
and allowed to remain about a minute.' It should be 
washed off with a stream of distilled water and dried 
between two layers of filter paper. When thoroughly dry, 
mount in balsam and examine. Some of the bacteria are 
easily discernible with the l /& dry objectives, others will 
require the -^ oil immersion. 

Tubercle bacilli must be stained with the carbol-fuchsin 
solution of Ziel. 

Parasites : Echinococcus cysts in or about the genito- 
urinary tract may empty into it. The urine will contain 
the contents of the cyst and hooklets of the entozoa. 

The strongylus gigas worm commonly found in the dog, 
on rare occasions may be found in the kidney pelvis of 



SIGNIFICANCE OF URINARY DEPOSITS. 371 

man. It may be mistaken for a blood cast of the ureter or 
vice versa. 

The embryos of the filiara sanguinis hominis may be 
found in the urine. 

In the tropics the distoma hsematobium may lodge in 
the membrane of the tract and give rise to local areas of 
suppuration. The discharge of eggs will determine the 
cause. They are more rounded at one end than at the 
other, and 0.12 millimeter long by 0.04 thick. 

Spermatozoa are seen in the urine of females voided soon 
after sexual intercourse. They are constantly present in 
spermatorrhoea. They are as far as semblance is concerned, 
small tadpoles with much elongated tails. If alive they 
are very active in their movements, being propelled by 
active gyrations of the tail. 



INDEX. 



A BNORMAL constituents of urine, 

A 351 

Abscess of the kidney, 173 

etiology of, 173. 
embolic infection, 174 
idiopathic, 174 

suppurative pyelonephrosis, 174 
traumatic, 174 
clinical history of, 175 
treatment of, 176 
Absence of the kidney or ureter, 135 
Acetonuria, 293 
Acidum aceticum, 313 
benzicum, 38, 120, 313 
carbolicum, 289, 313 
gallicum, 314 
hydrocyanicum, 290, 314 
muriaticum, 297 
nitricum, 39, 120, 168, 215, 227, 

232, 314 
nitro-muriatic, 307 
oxalicum, 307 

phosphoricum, 120, 232, 314 
picricum, 315 
salicylicum, 297 
Aconitum napellus, 120, 201, 263, 315 
Adenomata of the bladder, 70 
treatment of, 73 
of the kidney, 244 
Adonis vernalis, 315 
Albumin in the urine, 351 

tests for, 352 
Albuminuria, 293 
etiology of, 293 
treatment of, 294 
of pregnancy, 262 
etiology of, 262 



pathological anatomy of, 262 
clinical history of, 262 
treatment of, 263 
Alkaptonuria, 294 
Aloe socotrina, 121 
Alumina, 121 
Aminoform, 253 
Ammonium carbonicum, 289, 316 

picricum, 316 
Amyloid nephritis, 229 
etiology of, 229 
pathological anatomy of, 230 
clinical history of, 230 
diagnosis of, 231 
prognosis of, 231 
treatment of, 231 
Angeomata of the bladder, 70 
treatment of, 73 
of the kidney, 244 
Anomalies of the kidney, 134 
pelvis of the kidney, 135 
renal artery, 136 
ureter, 135 
Apis mellifica, 121, 201, 264, 316 
Apocynum cannabinum, 201, 317 
Argentum nitricum, 121, 167, 264, 

317 
Arnica montana, 121, 264, 318 
Arsenicum album, 121, 202, 213, 226, 

289, 318 
Arteries, malformation of, 136 
Aurum metallicum, 122, 226 

muriaticum, 319 
Azoturia, 310 

TDACILUNUM, 239 



r> 



Bacteria in the urine, 368 



Bacterial casts, 368 



374 



Bacteriuria, 295 

etiology of, 295 

pathological anatomy of, 296 

clinical history of, 296 

prognosis of, 297 

treatment of, 297 
Belladonna, 122, 202, 264, 319 
Benzoic acid, 38, 120, 313 
Berberis vulgaris, 39, 122, 167, 320 
Bile in the urine, 358 

test for, 359 
Bladder, absence of, 17 
anomalies of, 17 
exstrophy of, 19 

treatment of, 20 
foreign bodies in, 77 

clinical history of, 77 

diagnosis of, 77 

treatment of, 7S 
irritability of, 51 

etiology of, 51 

clinical history of, 51 

treatment of, 52 
malignant growths of, 69 

clinical history of, 70 

diagnosis of, 72 

prognosis of, 73 

treatment of, 73 
rupture of, 27 

etiology of, 27 

pathological anatomy of, 28 

clinical history of, 29 

diagnosis of, 30 

prognosis of, 30 

treatment of, 30 
stone in the, 79 
supernumerary, 17 
tumors of the, 69 
wounds of the, 25 

clinical history of, 26 

diagnosis of, 26 

prognosis of, 27 

treatment of, 27 

Blood in the urine, 360 

significance of, 360 



Blood casts, 368 
Bright' s disease, 186 
Bryonia alba, 159 
Buchu, 159 

/CAFFEINE, 320 
^ Calcarea carbonica, 123, 167, 
321 
hypophosphorica, 329 
iodata, 239 
Calcareous calculi, 255 
Calculous pyelitis, 157 
Calculus of the kidney, 248 
etiology of, 248 
clinical history of, 248 
calcareous carbonate, 250 
cystin, 249 
indigo, 249 
oxalate, 249 
phosphatic, 250 
uric acid, 249 
urostealith, 250 
xanthin, 250 
treatment of, 252 
Camphor, 123, 321 
Cancer of the kidney, 245 
Cannabis Indica, 123, 289, 321 

sativa, 321 
Cantharis, 123, 167, 202, 214, 289, 

322 
Carbo vegetabilis, 124, 322 
Carbonate of lime calculus, 249 
Carbonates in the urine, 349 

tests for, 349 
Carcinoma of the kidney, 245 
Casts, bacterial, 368 
blood, 368 
epithelial, 367 
fatty, 368 
hyaline, 367 
pus, 348 
waxy, 368 
Catherization of the ureter, 114 
Causticum, 124, 322 
Cavernous growths of the kidney, 
243 



375 



Cerefolious, 323 
Chelidonium major. 323 
Chimaphila umbellata, 39, 124 
Clinical significance of the urinary- 
deposits, 360 
China officinalis, 265 
Chininum sulphuricum, 124, 323 
Chloralum hydratum, 323 
Chlorides in the urine, 346 

tests for, 346 
Chyluria, 298 

etiology of, 298 
clinical history of, 298 
treatment of, 299 
Cicuta virosa, 203, 289 
Cina, 323 

Cirrhosis of the kidney, 218 
Coccus cacti, 125, 167, 324 
Coffea cruda, 265 
Colchicum autumnale, 125, 334 
Colic, renal, 165 
Colocynthis, 125 
Conium maculatum, 125 
Constituents of abnormal urine, 351 

of normal urine, 343 
Convallaria majalis, 324 
Copaiva, 39, 125, 325 
Crotalus, 302 
Croupous nephritis, acute, 190 

chronic, 209 
Cystic degeneration of the kidney, 

233 

etiology of, 233 

pathological anatomy of, 233 

clinical history of, 234 

treatment of, 235 
Cystin calculi, 249 
Cystinuria, 300 

etiology of, 300 

clinical history of, 300 
Cystitis, acute, 31 

etiology of, 31 

pathological anatomy of, 32 

clinical history of, 32 

diagnosis of, 34 



prognosis of, 34 
treatment of, 34 
chronic, 35 
etiology of, 35 
pathological anatomy of, 35 
clinical history of, 37 
treatment of, 38 
tubercular, 47 
etiology of, 47 
pathological anatomy of, 47 
clinical history of, 48 
diagnosis of, 49 
prognosis of, 50 
treatment of, 50 
Cystocele, 17 

treatment of, 18 
Cystoscopy as applied to men, 112 
Cystoscopy as applied to the diagno- 
sis and treatment of urinary- 
diseases in women, 96 
technique of, 99 
preparation of the patient, 99 
anaesthesia in, 100 
posture in, 100 
asepsis of 10 1 
instruments, 101 
illumination, 102 
ureteral catherization (Kelly 

method), 105. 
local treatment for, 108 
foreign bodies, 108 
vesico-vaginal fistulae, 109 
hyperemia of the trigone, 109 
chronic cystitis, 109 
tumors of the bladder, 1 10 
tubercular cystitis, no 
urethral lesions, no 
kidney lesions, no 
Cysts, dermoid, 233 

hydatids, 
Cubeba, 126 
Cuprum aceticum, 325 
arsenicosum, 203, 265, 2S9 
metallicum, 265 



376 



IXDEX. 



y^EATH'S crisis, 139 

-*-^ Depurative infiltration of the 

kidney, 229 
Dermoid cyst of the bladder, 70 
treatment of, 73 
of the kidney, 233 
Diaceturia, 300 
Digitalis purpurea, 126, 325 
Dioscorea villosa, 167 
Double kidney, 134 
Dulcamara, 39, 126, 326 

"pCLAMPSIA of pregnancy, 262 
J - / Equisetum hyemale, 126, 302 
Epithelial casts, 367 
Epithelium in the urine, 366 

significance of 366 
Equisetum hyemale, 327 
Erigeron canadensis, 126 
Eucalyptus, 39, 126 
Endotheliomata of the kidney, 243 
Euonyrnin, 326 
Eupatorium perfoliatum, 326 

T}ATTY casts, 368 

Ferrum muriaticum, 214, 327 
phosphoricum, 327 
Fibromata of the bladder, 70 

treatment of, 73 
of the kidney, 244 
Fistulse of the kidney, 171 

treatment of, 172 
of the ureter, 148 

treatment of, 148 
Floating kidney, 136 

etiology of, 136 

clinical history of, 138 

diagnosis of, 141 

treatment of, 143 
Formica rufa, 327 



GELSEMIUM sempevirens, 
265 
Globulin in the urine, 354 
test for, 354 



126, 



Globulinuria, 300 
Glomerulo nephritis, 209 
Glonoinum, 226, 265, 286, 327 
Glucose in the urine, 355 

test for, 356 
Glycosuria, 301 
Gouty kidney, 218 
Graphites, 127, 328 
Gravel, 251 



IT HEMATURIA, 301 
■*-*- treatment of, 302 
Haemoglobin in the urine, 355 

test for, 355 
Hemoglobinuria, 303 

etiology of, 303 

clinical history of, 303 

prognosis of, 304 

treatment of, 304 
Hamamelis Virginica, 302, 3 28 
Hedeoma pulegioides, 328 
Helleborus niger, 203, 289, 328 
Helonias dioica, 266, 329 
Hepar sulphur calcareum, 127, 329 
Hyaline casts 367 
Hydatid cysts of the kidney, 234 

etiology of, 234 

pathological anatomy of, 235 

treatment of, 235 
Hydrangea, 329 
Hydrastis Canadensis, 127 
Hydriothionuria, 304 
Hydrocyanic acid, 290, 314 
Hydronephrosis, 161 

etiology of, 161 

pathalogical anatomy of, 162 

clinical history of, 162 

diagnosis of, 163 

treatment of, 163 
Hydruria, 310 

Hyoscyamus niger, 127, 266 
Hypertrophy of the kidney, 134 

TGNATIA, 127, 329 

-*- Incontinence of urine, 53 



INDEX. 



377 



clinical history of, 53 

treatment of, 54 
Indicanurea, 304 
Indigo calculus, 249 
Inosituria, 305 
Injuries of the kidney, 170 

treatment of, 171 
to the ureter, 146 

treatment of, 147 
Insanity of uraemia, 287 
Interstitial nephritis, chronic, 218 
Ipecacuanha, 302, 329 

T7" ALI bichromicum, 329 



iS. 



Kali carbonicum, 330 



Kali chloricum, 331 
Kali iodide, 226, 231, 330 
Kali muriaticum, 214 
Kalmia latifolia, 330 
Kidneys, absence of, 135 
benign growths of, 244 
calculus in, 248 
carbonate of lime, 250 
cystin, 249 
indigo, 249 
oxulate, 249 
phosphatic, 249 
uric acid, 245 
urostealith, 250 
xanthin, 249 
congenital absence of, 134 
congestion, acute, of, 178 
etiology of, 178 
pathological anatomy of, 178 
clinical history of, 178 
prognosis of. 179 
treatment of, 179 
congestion, chronic, of, 180 
etiology of, 180 
pathological anatomy of, 180 
clinical history of, 181 
treatment of, 181 
contraction of, 218 
cystic degeneration of, 233 
etiology of, 233 



pathological anatomy of, 233 

clinical history of, 234 

treatment of, 235 
degeneration acute of, 183 

etiology of, 183 

pathological anatomy of, 183 

clinical history of, 184 

treatment of, 184 
degeneration, chronic of, 185 

etiology of, 185 

pathological anatomy of, 185 

clinical history of, 185 

treatment of, 186 
depurative infiltration of, 229 
double lobulated, 136 
fistulse of, 171 

treatment of, 172 
floating, 136 
granular atrophy of, 218 
growths, 243 

adenoma of, 244 

angioma of, 244 

carcinoma of, 245 

cavernous of, 243 

endothelioma of, 243 

fibroma of, 244 

hydatids of, 234 

hypertrophy of, 134 

lipoma of, 244 

lymphadenoma of, 243 

myoma of, 244 

myxolipoma of, 243 

papilloma of, 244 

sarcoma of, 245 

syphilitic gumma of, 243 

villous growth of, 243 
horseshoe formation of, 134 
injuries of, 170 

treatment of, 171 
lardaceous, 229 
malformations of the, 134 
malignant growths of the, 244 
movable, 136 

etiology of 136 

clinical history of, 13S 



378 



diagnosis of, 141 

treatment of, 143 
suppuration of the, 173 

etiology of, 173 

pathological anatomy of, 173 

clinical history of 175 

treatment of, 176 
supernumary, 134 
surgical, 173 
syphilis, 254 
waxy, 229 
Kreasotum, 127 

T ACHESIS, 127, 330 
- Lv Lactosuria, 305 
Lardaceous nephritis, 229 

etiology of, 229 

pathological anatomy of, 230 

clinical history of, 230 

diagnosis of, 231 

prognosis of, 231 

treatment of, 231 
Laevulosuria, 305 
Lipoma of the kidney, 244 
Lipuria, 305 

Lithium carbonicum, 226, 330 
Lycopodium clavatum, 128, 167, 231, 

330 
Lymphadenoma of the kidney, 243 
Lysidine, 307 

TV /TALFORMATION of the blad- 
-^-*- der, 17 

kidney, 134 

pelvis of the kidney, 135 

renal vessels, 136 

ureters, 135 
Malignant growths of the bladder, 
69 

of the kidney, 244 
Melanuria, 305 
Mercurius, 128 

corrosivus, 204, 214, 266, 331 

dulcis, 226, 332 
Movable kidney, 136 



etiology of, 136 
clinical history of, 138 
diagnosis of, 141 
treatment of, 143 
Mucin in the urine, 358 

test for, 358 
Mucus polypi of the bladder, 70 

treatment of, 73 
Mullein oil, 128 
Myomata of the bladder, 70 
treatment of, 73 
of the kidney, 244 
Myxolipomatous growth of the kid- 
ney, 243 

TyjEPHRECTOMY, 259 
■*• * abdominal, 260 

lumbar, 260 
Nephritis, acute, 182 

etiology of, 182 

clinical history of, 182 

prognosis of, 183 

treatment of, 183 
amyloid, 229 

etiology of, 229 

pathological anatomy of, 230 

clinical history of, 230 

diagnosis of, 231 

prognosis of, 231 

treatment of, 231 
catarrhal, 218 
croupous acute, 190 
croupous chronic, 209 
exudative, acute, 190 

etiology of, 191 

pathological anatomy of, 193 

clinical history of, 195 

prognosis of, 200 

treatment, general, 205 
medical, 201 
exudative, chronic, 209 

etiology of, 209 

pathological anatomy of, 206 

clinical history of, 210 

diagnosis of, 213 



379 



prognosis of, 213 
treatment general, 215 

medical, 213 
interstitial, 218 
etiology of, 218 
pathological anatomy of, 221 
clinical history of, 221 
diagnosis of, 225 
prognosis of, 226 
treatment general, 227 

medical, 226 
parenchymatous, acute, 190 
etiology of, 191 
pathological anatomy of, 193 
clinical history of, 195 
prognosis of, 200 
treatment, medicinal, of, 201 

general, of, 205 

surgical, of, 207 
parenchymatous, chronic, 209 
etiology of, 209 
pathological anatomy of, 209 
clinical history of, 210 
diagnosis of, 213 
prognosis of, 213 
treatment, medicinal, of, 213 

general, of, 216 
post-scarlatinal, 190 
productive, acute, 190 
etiology of, 191 
pathological anatomy of, 193 
clinical history of, 195 
prognosis, 200 
treatment, medicinal, of, 201 

general, of, 205 

surgical, of, 207 
productive, chronic, 209 
red granular, 218 
suppurative, 173 

etiology of, 173 

pathological anatomy of, 173 

idiopathic form, 173 

traumatic form, 173 

suppurative pyelonephrosis, 

173 
infectious emboli, 173 



clinical history of, 175 

treatment of, 176 
syphilitic, acute, 241 

etiology of, 241 

pathological anatomy of, 241 

clinical history of, 241 

prognosis of, 241 

treatment of, 241 
syphilitic, chronic, 241 

etiology of, 241 

pathological anatomy of, 24 r 

clinical history of, 242 

treatment of, 242 
tubal, acute, 193 
tubal, chronic, 209 
Nephropexy, 257 
Nephroptosis, 136 

etiology of, 136 

clinical history of, 138 

diagnosis of, 141 

treatment of, 143 
Nephrolithotomy, 259 
Nephrorrhaphy, 257 
Nephrotomy, 259 
Nitric acid, 39, 120, 168, 215, 227, 

232, 314 
Nitro-muriatic acid, 307 
Normal constituents of urine, 343 
Nux vomica, 128, 168, 217, 227, 302, 
332 

f~\CIMUM canum, 332 
" Opium, 129, 266, 290, 332 
Oxalicum acidum, 165, 239 
Oxalic acid in the urine, 350 

tests for, 350 
Oxaluria, 306 

etiology of, 306 

clinical history of, 306 

treatment of, 307 
Oxalate calculus, 249 
Oxydendron arboreum, 332 

T)APIIvIX>MATA of the bladder, 69 



r 



treatment of, 



380 



of the kidney, 244 
Parasites in the urine, 370 

significance of, 370 
Pareira brava, 40, 129, 168 
Petroleum, 129, 332 
Patulous urachus, 23 
treatment of, 24 
Peperzin, 252 
Phosphatic calculus, 249 
Phosphates in the urine, 347 

tests for, 348 
Phosphaturia, 308 
functional, 308 
etiolog} 7 of, 308 
clinical history of, 308 
secondary, 309 

etiology of, 309 
true, 308 

etiology of, 308 
clinical history of, 308 
treatment of, 309 
Phosphoric acid, 120, 232, 314 
Phosphorus, 129, 215, 333 
Phytolacca decandra, 333 
Pichi, 168, 333 
Picric acid, 315 
Pilocarpin muriaticum, 333 
Plumbum metallicum, 129, 227, 333 
Polyuria, 310 
persistent, 310 
transient, 310 
treatment of, 311 
Populus tremuloides, 130 
Prunus spinosa, 130 
Pulsatilla nigricans, 40, 129, 334 
Pus casts, 363 
in the urine, 365 
significance of, 365 
Pyelitis, 153 

etiology of, 153 
calculous, 153 
primary, acute, 153 

chronic, 153 
secondary, acute, 154 
chronic, 154 



traumatic, 153 
tubercular, 153 
pathological anatomy of, 154 
primary acute, 154 

chronic, 154 
secondary acute, 154 

chronic, 154 
clinical history of, 155 
calculous, 157 
primary acute, 155 

chronic, 155 
secondary acute, 157 

chronic, 159 
traumatic, 157 
tubercular, 157 
prognosis of, 159 
treatment of, 159 
Pyelolithotomy, 258 
Pyelonephritis, 173 

treatment of, 176 
Pyonephrosis, 164 
etiology of, 164 
pathological anatomy of, 164 
clinical history of, 165 
treatment of, 165 
Pyuria, 309 

etiology of, 310 
clinical history of, 310 
treatment of, 310 

"T~> BNAL anomalies, 134 
-^ arteries, 136 
calculus, 243 

etiology of, 248 

clinical history of, 249 

treatment of, 252 
cirrhosis, 218 
colic, 165 

etiology of, 165 

clinical history of, 165 

prognosis of, 167 

treatment of, 167 
congestion, acute, 178 

etiology of, 178 

pathological anatomy of, 178 



381 



clinical history of, 178 

prognosis of, 179 

treatment of, 179 
chronic, 180 

etiology of, 180 

pathological anatomy of, 180 

clinical history of, 181 

treatment of, 184 
crisis, 139 
degeneration, acute, 183 

etiology of, 183 

pathological anatomy of, 183 

clinical history of, 184 

treatment of, 184 
chronic, 185 

etiology of, 1 85 

pathological anatomy of, 185 

clinical history of, 185 

treatment of, 186 
fistulae, 171 

etiology of, 171 

clinical history of, 172 
cutaneous, 172 
gastric, 172 
intestinal, 172 
reno-bronchial, 172 

treatment of, 172 
injuries, 170 

etiology of, 170 

clinical history of, 170 

treatment of, 171 
sclerosis, 218 
syphilis, 241 
surgery, 254 
tuberculosis, 236. 

etiology of, 236 

pathological anatomy of, 237 

clinical history of, 237 

treatment of, 239 
tumors, 243 

etiology of, 244 

clinical history of, 245 

prognosis of, 246 

treatment of, 246 
Reno-bronchial fistulae, 172 



cutaneous fistulae, 172 
gastric fistulae, 172 
intestinal fistulae, 172 
Retention of urine, 57 
pathology of, 57 
clinical history of, 58 
from congestion or inflamma- 
tion, 59 

treatment of, 59 
from prostatic enlargement, 59 

treatment of, 61 
from sudden obstruction of the 
internal opening of the 
urethra, 64 
treatment of, 65 
from paralysis or in co-ordina- 
tion of the bladder mus- 
cle, 66 
treatment of, 66 
from urethral stricture, 67 
treatment of, 67 
Rhus aromatica, 130, 204 
Rhus toxicodendron, 130, 334 
Ruta graveolens, 130 

o ABAL serrulata, 40, 131 
^ Sabina, 131, 334 
Salicylic acid, 297 
Sambucus, 335 
Sandal-wood, 130, 335 
Sarcomata of the bladder, 70 

treatment of, 73 
of the kidney, 
Sarsaparilla, 131, 335 
Secale cornutum, 336 
Selenium, 131 
Senecio aureus, 336 
Senna, 336 
Sepia, 131, 336 
Serous cysts of the bladder, 70 

treatment of, 73 
Significance of the urinary sedi- 
ments, 360 
Spermatozoa in the urine, 371 
Staphisagria, 132 
Strangury, 55 



382 



treatment of, 55 
Stigmata maidis, 132, 168, 336 
Stone in the female bladder, 95 
treatment of, 95 

in the male bladder, 79 
Stramonium, 266, 337 
Syphilis of the kidney, 241 
Sulphates in the urine, 349 

test for, 350 
Sulphur, 40, 132, 337 
Suppuration of the kidney, 173 
Sugar in the urine, 355 

test for, 355 
Surgical kidney, 173 

np ABA CUM, 168 

Terebinth, 132, 204, 267, 302, 

337 
Thlaspi bursa pastoris, 168, 302, 337 
Thuja occidentalis, 41, 132 
Tissue in the urine, 367 
Traumatic pyelitis, 156 
Traumatism of the kidney, 170 

treatment of, 171 
Tube casts, 367 
bacterial, 368 
blood, 368 
epithelial, 367 
fatty, 368 
hyaline, 367 
pus, 368 
waxy, 368 
Tubercular pyelitis. 157 
Tuberculosis of the kidney, 236 
etiology of, 236 
pathological anatomy of, 237 
clinical history, 237 
treatment of, 239 
Tumors of the bladder, 69 
etiology of, 70 
clinical history of, 70 
diagnosis of, 72 
prognosis of, 73 
treatment of, 73 
of the kidney, 243 
etiology of, 236 



pathological anatomy of, 243, 

245 
clinical history of, 245 

capsular, 243 

extra-renal, 243 

glandular, 243 

pelvic, 243 
treatment of, 247 

TTLEX diureticus, 338 
^ Urachus patulous, 23 
Uraemia, 273 

etiology of, 273 

clinical history of, 279 

diagnosis of, 288 

prognosis of, 288 

treatment of, 289 
Uranium nitricum, 267, 338 
Urea in the urine, 343 

test for, 343 
Ureteral obstruction, 150 

treatment of, 151 
fistular, 148 

treatment of, 148 
injuries, 146 

treatment of, 147 
Ureteritis, 149 

etiology, 149 

clinical history of, 149 

treatment of, 149 
Ureters, malformations of, 135 
Uric acid calculus, 249 
in the urine, 345 

test for, 345 
Uricacidurea, 311 

etiology of, 311 

clinical history of, 311 

treatment of, 312 
Urinary incontinence, 53 

clinical history of, 53 

treatment of, 54 
Urinary retention, 57 

pathology of, 57 

clinical history of, 58 

from congestion or inflamma- 
tion, 59 



INDEX. 



383 



treatment of, 59 
from prostatic enlargement, 59 

treatment of, 61 
from sudden obstruction of 
the internal opening of 
the urethra, 64 
treatment of, 65 
from paralysis or inco-ordina- 
tion of the bladder muscle, 
66 
treatment of, 66 
from urethral stricture, 67 
treatment of, 67 
segregation, Harris method, 115 
sediments, their significance, 360 
Urostealith calculus, 250 
Uva ursi, 133, 168, 338 
Urine, examination of, 339 
color of, 339 
quantity of, 339 
reaction of, 339 
specific gravity of, 341 
abnormal constituents of, 351 
albumin, 351 

detection of, 352 
bile, 358 

detection of, 359 
globulin, 354 

detection of, 354 
glucose, 355 

detection of, 356 
haemoglobin, 355 

detection of, 355 
mucin, 358 
detection of, 358 
clinical significance of urinary 
sediments, 360 
bacteria, 368 
non-pathogenic, 368 
pathogenic, 368 

bacillus coli communis, 369 
gonococcus of Neiser, 369 
tubercle bacillus, 370 
typhoid bacillus, 369 
blood, 360 



epithelium, 366 

bladder, 366 

pelvis of the kidney, 366 

prostatic, 367 

tubules of the kidney, 366 

urethral, 366 

vaginal, 366 
parasites, 370 

distoma haematobium, 371 

echinococcus, 370 

filiara sanguinis hominis, 317 

strongylus gigas worm, 370 
spermatozoa, 371 
tissue, 367 
tube casts, 367 

bacterial, 368 

blood, 368 

epithelial, 367 

fatty, 368 

hyaline, 367 

pus, 368 

waxy, 368 
normal constituents of urine, 343 
carbonates, 349 

detection of, 349 
chlorides, 346 

detection of, 346 
oxalic acid, 350 

detection of, 350 
phosphates, 347 

detection of, 348 
sulphatis, 349 

detection of, 350 
urea, 343 

detection of, 343 
uric acid, 345 

detection of, 345 

T 7BRATRUM viride, 205, 267 
Vesical calculus, 79 
etiology of, 80 
clinical history of, 81 
treatment non-operative, S4 
treatment, operative, 85 
tenesmus, 55 



AUG 4 WOO 



384 



INDEX. 



treatment of, 55 
therapeutics, 120 
tumors, 69 

adenomata, 70 

angeomata, 70 

carcinomata, 70 

dermoid cysts, 70 

fibromata, 70 

myomata, 70 

mucous polypi, 70 

papillomata, 69 

sarcomata, 70 

serous cysts, 70 

clinical history of, 70 



diagnosis of, 72 

prognosis, of, 73 

treatment of, 73 
Vesicaria communis, 133, 138 
Villous growths of the kidney, 243 
rAXY casts, 368 



W A 



YANTHIN calculus, 249 



^INGIBBR, 338 



